Defensible documentation using the endoscopy pathway.
Complete, defensible documentation in a busy endoscopy unit can be elusive. Quick turnaround time, impatient physicians, and add-on and emergent cases all contribute to chaotic days. The endoscopy pathway provides a guided path for succinct documentation by the healthcare worker. A scoring system is initiated on admission. Assessment parameters clearly define scores for vital signs, level of consciousness, abdominal status, pain, safety, and mobility. Scores can be scanned quickly and compared by the nurse to identify significant changes in each patient. Documentation is timely, communicative, and complete. The endoscopy pathway is illustrated by a case study. It reflects patients' progress throughout their stay in the GI unit from admission to discharge. The implementation process of this innovative chart form is presented.
Anderson
P
P
HealthEast Gastroenterology Services, St. Paul, Minnesota 55104, USA.
Rodlund
J L
JL
D019091:Critical Pathways / Q000458:organization & administration*; D004282:Documentation / Q000592:standards*; D004509:Education, Nursing, Continuing; D004724:Endoscopy / Q000451:nursing*; D005568:Forms and Records Control; D006801:Humans; D007318:Inservice Training; D007591:Joint Commission on Accreditation of Healthcare Organizations; D009730:Nursing Assessment; D009737:Nursing Records / Q000592:standards*; D009741:Nursing Staff, Hospital / Q000193:education; D010343:Patient Admission; D010351:Patient Discharge; D017749:Total Quality Management / Q000458:organization & administration