Documenting nursing process in the perioperative setting. Continuity of care, patient evaluation.
Using our Perioperative Nursing Process form in addition to intraoperative and PACU flow sheets allows us to document the nursing process in a manner that satisfies the goals for documentation established by our committee. Because we place all forms in the patients' medical records, they are available for review by the JCAHO to prove that we comply with their standards and the standards of AORN and ANA. The nurses have been satisfied with the documentation system because it can be used efficiently and does not require redundant documentation as the patient transfers into each perioperative area.
Pobojewski
B J
BJ
Surgery department, Ferguson Hospital, Grand Rapids, Mich.
Neper
N
N
Guzzo
P M
PM
Beadle
P K
PK
D003266:Continuity of Patient Care; D004282:Documentation / Q000379:methods*; D005568:Forms and Records Control; D006801:Humans; D008824:Michigan; D009730:Nursing Assessment; D009736:Nursing Process; D009737:Nursing Records; D009871:Operating Room Nursing