Goals of documentation?
Support Perioperative nurse workflow Facilitating data Eliminating redundancies Reflecting patient focused care Contain all important info for ongoing and transitional care
6 steps of nursing process?
Assessment Nursing dx Outcome identification Planning Implementation Evaluation
How must info be documented?
Systematically and consistently
Issues that arise with data?
Responsibilities is nursing process?
Safety Education - pt & fam Planning - continuity Communication Appropriate care - culturally, ethically, age appropriate
Document throughout entire nursing process
Incorporate standardized clinical terminology
Accurate data to measure and evaluate pt outcomes
Storage and extraction
PNDS - standardized nursing language
Electronic health records?
Info available instantly and securely
Benefits of EHR?
Improve pt care Increase pt participation Improve care coordination Improve diagnostic and pt outcomes Cost saving
Downtime for EHR?
Ensure pt care is not interrupted
Alternate data entry
Back up protocols
How to document?
State info clearly
Individualized per pt
Will understand in future
- able to explain what care was provided, supportive
When can you have verbal orders?
Only when clinically indicated
How to document verbal orders?
Enter in ASAP Read back Record names and roles No abbreviations No trailing zeros Standardized names and terms Follow P&P for standing orders
When should you make corrections?
Should only be done to present accurate description of care or protect or interest
How to decrease malpractice lawsuit with documentation?
Documentation should be.. F - factual A - accurate C - complete T - timely
What causes lawsuit?
Failure to: Communicate Document Assess/ monitor Follow standards of care Act as pt advocate Use equipment in reasonable manner
Whose risk reductions should you follow?
Standards of Perioperative nursing
- define and enumerate responsibilities
AORN guidelines for Perioperative practice
- recommendations for Perioperative pt care
Ethical and legal right to act autonomously
- research interventions
- pt wishes
Who gathers consent?
Surgeon, anesthesiologist and/or other licensed practitioners
Nurse - can witness consent, review consent forms
HIPPA? And nurses role?
Protect bodies from more exposure than required
Never comment in and outside of pt care areas
How does HIPPA affect health care facilities?
Pt consent - how info will be used
Privacy and security - limit use or disclosure of info
Administrative procedures - protect privacy and confidentiality
Perioperative protocols - P&P
Documentation about dressings?
Documentation about tourniquet?
Times of inflation and deflation
Reactions to ischemia and reperfusion
Documentation about lasers?
Total energy used
Documentation about positioning?
Type and location
Actions to prevent injury
Type and location of safety restraints
What is evaluated right before sending pt to PACU?
- type and presence of an airway
- oxygen flow rate