OBJECTIVE: The purpose of this analysis was to establish professional nursing practice standards for perioperative documentation. The goal was to provide clinicians and software developers with a national model for perioperative documentation. The objective was to: 1) facilitate the identification of data elements that represent professional nursesí contributions to patient outcomes in surgical settings, and 2) establish a framework for a national perioperative database that will facilitate comparisons across information systems and clinical settings.
DESIGN: A national sample of over 150 perioperative records currently in use representing both inpatient and ambulatory settings in were collected and analyzed so as to identify common data elements.
SAMPLE: The sample consisted of paper and computerized records representing clinical practice settings from for-profit, non-profit, and government agencies. Facilities ranged in size from 45 to over 900 beds and performed on the average of 500 surgeries each month. Intraoperative records ranged in length from one to seven pages.
CONCEPT: This analysis involved the identification of data elements collected by nurses during the intraoperative experience and the consistency of their use across clinical settings. The goal was to establish documentation standards by evaluating current documentation practices.
METHODS: A national sample of over 150 perioperative records representing both inpatient and ambulatory settings from for-profit, non-profit, and government agencies were collected and analyzed. Data elements that represented the intraoperative period were noted using a structured format. Two expert nurses conducted the analysis and achieved a high-level of inter-rater reliability when coding the clinical records.
FINDINGS: This analysis uncovered a disappointing reality about the current status of intraoperative nursing documentation. One major finding included the marginal consistency in the collection of structural data elements (i.e. start time, stop time, anesthesia type, and wound classification). Also, in fewer than 22% of the records were nursing diagnoses, interventions, and patient outcomes documented.
CONCLUSIONS: In surgical settings, the professional aspects of intraoperative nursing care are embedded in the care delivered and not accurately or fully represented in clinical documentation. To understand the contributions of perioperative nurses to surgical outcomes, the framework for documentation must be structured in a manner that includes nursing diagnoses, interventions, and outcomes. The benefits of structured vocabulary can only be fully realized when national documentation standards are established and implemented within and across settings.
IMPLICATIONS: Professional nurses must document the care they provide in a manner that represents the professional aspect of their care. Nursing contributions can not be fully evaluated unless they represented and documented in clinical records. The use of structured vocabulary may assist nurses accept and utilize standardized terms, but the most important factor is a nursing record that fully represents and describes professional nursing practice. The ability to computerize clinical records will not help in to evaluate the effectiveness of nursing practice unless assessments, identified problems, interventions, and outcomes are consistently and appropriately documented.
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