A guide to revising the postanesthesia care unit documentation record.
The environment of the PACU is changing rapidly, as are the standards, protocols, and requirements of documentation. Nursing care activities must be captured in a timely, accurate, and efficient manner that reflects the standards of care and quality practice, while reducing the amount of actual writing required. This article reviews the available literature and defines a process to guide one through the revision of a documentation record.
Rybak
S
S
Ottawa Hospital, Post Anaesthesia Care Unit, Ontario, Canada.
Bush
P
P
D004282:Documentation / Q000592:standards*; D005568:Forms and Records Control; D006801:Humans; D007587:Job Description; D009731:Nursing Audit / Q000379:methods*; D009737:Nursing Records / Q000592:standards*; D016528:Postanesthesia Nursing / Q000379:methods / Q000592:standards*; D017749:Total Quality Management / Q000458:organization & administration