The ideal state for perioperative nursing.
For a typical surgical procedure, a minimum of three individuals document the care provided during the intraoperative phase. This makes it difficult to develop perioperative records with pertinent data elements without creating redundancy, errors, and inconsistencies. This article discusses strategies to develop surgical records that share information effectively through the use of structured vocabulary and a thoughtful approach to professional nursing practice. It begins to explore developing standards for paper or electronic documentation through collaboration with other stakeholders, including anesthesia care providers, surgeons, clinical directors, and informaticians.
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D003625:Data Collection; D004282:Documentation; D006801:Humans; D007430:Intraoperative Care; D008499:Medical Records / Q000592:standards*; D010347:Patient Care Planning / Q000458:organization & administration; D013527:Perioperative Nursing / Q000458:organization & administration*; D011364:Professional Practice; D014481:United States; D018875:Vocabulary, Controlled