Informatics Standards in Perioperative Nursing; an Analysis of Documentation Standards

2.50
Hdl Handle:
http://hdl.handle.net/10755/151788
Type:
Presentation
Title:
Informatics Standards in Perioperative Nursing; an Analysis of Documentation Standards
Abstract:
Informatics Standards in Perioperative Nursing; an Analysis of Documentation Standards
Conference Sponsor:Sigma Theta Tau International
Conference Year:2001
Conference Date:June, 2001
Author:Beyea, Suzanne, PhD
P.I. Institution Name:AORN
Title:Director of Nursing Research
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 nurses' contributions to patient outcomes in surgical settings, and 2) establish a framework for a national database of perioperative nursing that will allow comparisons across information systems and clinical settings. Design: A national standard of over 150 perioperative records currently in use representing both inpatient and ambulatory settings in were collected and analyzed. 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: 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. Terms on the documentation forms that could not be coded using the structured format were noted and referred to an expert panel of certified perioperative nurses. Through an iterative process consensus on those terms was achieved. Although many terms were very seemingly very different, in essence had the same clinical definitions or uses. 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, wound classification). Also, in fewer than 22% of the records were nursing diagnoses, nursing interventions, or 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 a 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 aspects of their care. Nursing contributions cannot be fully evaluated unless they represented and documented in clinical records. The use of structured vocabulary may assist nurses adopt structured terms, but the most important factor is a nursing record that fully describes 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.
Repository Posting Date:
26-Oct-2011
Date of Publication:
Jun-2001
Sponsors:
Sigma Theta Tau International

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleInformatics Standards in Perioperative Nursing; an Analysis of Documentation Standardsen_GB
dc.identifier.urihttp://hdl.handle.net/10755/151788-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Informatics Standards in Perioperative Nursing; an Analysis of Documentation Standards</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Sigma Theta Tau International</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2001</td></tr><tr class="item-conference-date"><td class="label">Conference Date:</td><td class="value">June, 2001</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Beyea, Suzanne, PhD</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">AORN</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Director of Nursing Research</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">sbeyea@empire.net</td></tr><tr><td colspan="2" class="item-abstract">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 nurses' contributions to patient outcomes in surgical settings, and 2) establish a framework for a national database of perioperative nursing that will allow comparisons across information systems and clinical settings. Design: A national standard of over 150 perioperative records currently in use representing both inpatient and ambulatory settings in were collected and analyzed. 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: 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. Terms on the documentation forms that could not be coded using the structured format were noted and referred to an expert panel of certified perioperative nurses. Through an iterative process consensus on those terms was achieved. Although many terms were very seemingly very different, in essence had the same clinical definitions or uses. 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, wound classification). Also, in fewer than 22% of the records were nursing diagnoses, nursing interventions, or 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 a 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 aspects of their care. Nursing contributions cannot be fully evaluated unless they represented and documented in clinical records. The use of structured vocabulary may assist nurses adopt structured terms, but the most important factor is a nursing record that fully describes 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.</td></tr></table>en_GB
dc.date.available2011-10-26T11:13:43Z-
dc.date.issued2001-06en_GB
dc.date.accessioned2011-10-26T11:13:43Z-
dc.description.sponsorshipSigma Theta Tau Internationalen_GB
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