Describing Professional Nursing Through a Universal Record in Perioperative Settings

PURPOSE

To establish professional nursing practice standards for perioperative documentation in order to provide clinicians and software developers with a national model for perioperative documentation.

METHODS

The sample consisted of paper and computerized records representing clinical practice settings from for-profit, nonprofit, and government agencies. Facilities ranged in size from 45–>900 beds and performed, on average, 500 surgeries each month. Intraoperative records ranged from 1–7 pages.

A national sample of more than 150 perioperative records representing both inpatient and ambulatory settings were collected and analyzed to identify common data elements. 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 interrater 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 (e.g., start time, stop time, anesthesia type, wound classification). Also, nursing diagnoses, interventions, and patient outcomes were documented in fewer than 22% of the records.

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. This effort resulted in the development of a best practice model for a nursing preoperative assessment and intraoperative documentation that has been adopted by clinicians and software developers.

Professional nurses must document the care they provide in a manner that represents the professional aspect of their care. Nursing contributions cannot be fully evaluated unless they are represented and documented in clinical records. The use of structured vocabulary may assist nurses to 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 evaluating the effectiveness of nursing practice unless assessments, identified problems, interventions, and outcomes are consistently and appropriately documented.