Adapting charting by exception to the perianesthesia setting.
Many acute care settings are experiencing a shift toward ambulatory patient care and are being pressured to decrease patient length of stay. Meanwhile, there is increased pressure to remain patient centered and to become more customer oriented. This article describes how the authors adapted charting-by-exception principles to develop a single ambulatory surgery nursing record for use from admission to discharge. The authors' goals were to condense documentation, to decrease time spent on documentation, and to diminish the variance in quality of documentation. This article also details how the new nursing record measures achievement of patient outcomes, with a focus of promoting street readiness.
Anderson
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LA
John Dempsey Hospital, University of Connecticut Health Center, Farmington 06030, USA. Landerson@up.uchc.edu
Schramm
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CA
D000556:Ambulatory Surgical Procedures / Q000451:nursing*; D004282:Documentation / Q000592:standards*; D005568:Forms and Records Control; D006801:Humans; D007902:Length of Stay; D009737:Nursing Records / Q000592:standards*; D009741:Nursing Staff, Hospital / Q000193:education / Q000523:psychology; D016528:Postanesthesia Nursing / Q000379:methods / Q000592:standards*; D017748:Time Management