Perioperative documentation. Integrating nursing diagnoses on the patient record.
The perioperative record maintains accurate communication between the OR and the postoperative care nurse. For example, the nurse can easily verify the type and placement of a drain by checking the area labeled "Potential for infection." The check-off format also makes the information consistent and easy-to-read, and the nurse does not have to decipher any handwriting. Another advantage of this format is that it is easy to retrieve data for nursing research. It is also suitable for computerization.
Stanfield
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Community Memorial Hospital, Monomonee Falls, Wis.
D006801:Humans; D007430:Intraoperative Care; D009730:Nursing Assessment; D009733:Nursing Diagnosis; D009737:Nursing Records; D009871:Operating Room Nursing; D010351:Patient Discharge; D011300:Preoperative Care