title: Quality improvement in documentation of postoperative care nursing using computer-based medical records.
abstract: Postanesthesia nursing should be documented with high quality. The purpose of this retrospective case-based study on 49 patients was to analyze the quality of postoperative documentation in the two existing templates and, based on this audit, to suggest a new template for documentation. The audit on the template with quantitative data showed satisfactory documentation of postoperative care nursing in 67% (18% to 92%; mean [min-max]) of the scores. The template for documentation using qualitative descriptions was used by 63% of the nurses, but the keywords were used to a varying degree, that is, from 0% to 63% of records. The analysis also revealed noncompliance with clinical guidelines and multiple duplicate entries. Based on this audit, a new template was constructed, with 10 physiological parameters and drop-down lists with keywords within each parameter. In this way, implicit knowledge could be converted to explicit documentation. Furthermore, the quality of documentation was improved.
authors.affiliation: Department of Anaesthesia and Intensive Care, Odense University Hospital, Odense, Denmark. susanne.olsen@ouh.regionsyddanmark.dk
authors.forename: Susanne Winther
authors.initials: SW
authors.lastname: Olsen
mesh_terms: D016347:Medical Records Systems, Computerized / Q000592:standards*; D009729:Nursing; D011182:Postoperative Care / Q000592:standards*; D058996:Quality Improvement