Outpatient Surgery Documentation: Incorporating Nursing Diagnoses

AORN JOURNAL

JANUARY 1991, VOL. 53, NO 1

Outpatient Surgery Documentation INCORPORATING NURSINGDIAGNOSES Carol Poss, RN

M

any changes have occured in the long history of perioperative nursing. These changes are most evident in nursing documentation.When SouthwestTexas Methodist Outpatient Surgery Center (OPSC), San Antonio, first opened in May 1980, the nursing documentation was two-pages long. This was later revised to a one-page two-sided form with a non-carbon copy sheet attached. A separate eye laser sheet became necessary to better document our outpatient laser treatments. After many revisions, we have implemented revised documentation that incorporates AORN nursing outcome standards.' The publication of AORN patient outcome standards was both timely and extremely helpful to us. The record now consists of a preoperative Carol Poss, RN,BS, is a staff development nurse in the outpatient surgery department of Southwest Texas Methodist Hospital, San Antonio. She earned her diploma in nursing at Baptist Memorial Hospital School of Nursing, San Antonio, Texas, and her bachelor of science degree in allied health sciences at Southwest Texas State Universiw, San Marcos. The author wishes to thank Joan Kelb, RN,BSN, director outpatient surgery, Glenda Kupferle, Rh?MSN, medical/surgical clinical nurse specialist, and Kathy Bower, RN,MSN, administrative assistant/nursing, and the staff of OPSC for their help in the preparation of the outpatient surgical center documentation.

record (Fig I), an intraoperative record with a non-carbon copy (Fig 2), a patient care plan (Fig 3), and one record, (Fig 4 and 5 ) for the recovery and advanced recovery (observation) phases. Revision of perioperative documentation has been an ongoing project and was necessary for several reasons. There was not enough space to properly chart new technology (ie, arthroscopic pumps, phacoemulsification machines, laser machines), There was not enough space to document preoperative teaching and discharge planning. The hospital clinical ladder program for nurses required more thorough documentation. The emphasis on the same level of care for inpatientsand outpatients required that more information be incorporated in nursing documentation. It was necessary to include a nursing care plan.

The Revision

T

he first step in revising our forms was to have the nurses in each unit of OPSC review their records and give their input. Many nurses had been to seminars and brought back samples of other records. They used some of this information in revising each OPSC unit nursing record. In order to review nursing diagnoses, we held several in-service programs with the hospital's 81

AORN JOURNAL

JANUARY 1991, VOL. 53, NO 1

PRE-OP NURSING NOTES

) " PULSE

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MENTAL STATUS

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PRE-OPERATIVE CALL I DISCHARGE P U N

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Fig 1. Preoperative nursing notes. All figures reprinted with permh i o n from Southwest Texas Methodirt Hospital, San Antonio. 83

JANUARY 1991, VOL. 53, NO I

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OPERATING ROOM NURSES NOTES

I

MED

ADMlN BY

ROUTE

~

R Name

Date

ALLERGIES OR # SURGEON(S) ASSISTANT(S) ANESTHESIOLOGIST RELIEF

TIME

CIRCULATOR 1ST SCRUB

~

URINARY DRAINAGE 0 NIA OStraight Cath Size Fr FOLEY Size Inserted by 0 In place on arrival to 0 R TOTAL OUTPUT IN 0 R

0 NIA

DRAINS ROOM TIME START ANESTHESIA

0 General

0 Spinal 0 MAC 0 Mask

0 EndotrachPalTube 0 Nasotracheal Tube

0 Regional 0 0, via nasal can

0 Amsco 0 NIA

PRESSURE POINTS PADDED

COUNTS SPONGES O N I A #t 0 Correct 0 Not Correct

0 Popliteal

n

EOUIPMENT 0 N/A Laser 0 Type Hyperthermia Unit# ELECTROSURGICAL UNIT 0 Monopolar

0 Microscope

0 Elbows OSupport 0 Support

Y U" I

WNL

O s e e Comments

OYes # O R t Arm

0 See Comments #1 Time Up-Time #2 TirneUp-Time

DownDown-

Total -min Total -min

~

WOUND CLASSIFICATION

~

SCRUB

~

0I

II 0 1 1 1

t

0 IV

€ILooD Loss

cc

DRESSING CULTURE OYes SOURCE SPECIMEN OYes

Temp

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'

0 Video 0 Other

0 N/A Unit # 0 Bipolar 0 Ground

~

CIRCULATOR

SHARPS NA I w1 0 Correct 0 Not Correct U2 0 Correct 0 Not Correct INSTRUMENTS 0 NIA 0 Correct 0 Not Correct

0 Chan Resl

0 Yes OChest 0 Chest Other

SAFETY STRAP SECURED 0 N/A OArmboard AT ARM OSide 0 Armboard LT ARM 0 Side 0 Legs Uncrossed LEGS

PREP

y i

OChest ~ 0 1 1 s

0 OCL

0 Fibercast

0NO 0 N/A 0 Autologous 0 Other

0 Other

0 Heels 0 Other

0 N/A

0 lodoform

0Other 0Yes 0Fluoroscan

BLOOD ADMINISTERED

0 Bean Bag -0 Head Foam Pad 0 Tape 0 Ax Roll 0 Sandbag 0 Foam Pads 0 Gel

Pads -0 Pillow Knees 0 Other OShoulder roll

0 Plaster

Lateral

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0 Plain 0 Vaseline 0 Other

0 N/A

X-RAYS TAKEN IN 0 R

0Other Prone 0 Left 0 Jackknife

OSupine 0 Rt 0 Litholomy

0Olher

Site CASTING MATERIAL

0Pulse Oximeter

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PERIOPERATIVENOTESINURSE S SIGNATURE

O N / A Solution BY

-1x ~~

O P E R A T I N G R O O M N U R S E S NOTES Y - 0 6 8 (21901

Fig 2. Operating room nurse's notes. 84

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JANUARY 1991. VOL. 53. NO 1

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clinical specialist who revised each aspect of the patient outcome standards. In revising the intraoperative record, we began with the record used in the main operating room. This record was much too lengthy and detailed for the OPSC, but we wanted to have as much similarity as possible. In our new form, each section was indented and divided by darker lines, so it could be viewed as a unit. For example, the electrosurgical and tourniquet sections, if not applicable, could be quickly completed by checking the “NA” block. This eliminated the need to read through or fill in any further portion of that section of the record. After the entire staff reviewed the revised record, the clinical nurse specialist went over the new record to make sure that each patient outcome was verified by entries in the perioperative notes. A final check with the staff in each area was done, and the records were sent to the printer for a final draft. After the hospital medical records department had reviewed and accepted the final draft, the records were sent to be printed. We found that the recovery record could be printed by our hospital printing department, which aided in cost containment. In an effort to keep our forms short, only the nursing diagnoses, patient outcome standards, and checklist column for evaluation were included on the perioperative record. To assist perioperative nurses in filling out the forms, we made copies of the AORN patient outcome standards and enclosed them in transparent page covers. These were put in each operating room for quick reference.

arranges for a tour of the unit. The preoperative nurses perform a nursing assessment at this time along with arranging any lab work ordered by the physician. The nurse who conducts this program begins the preoperative documentation and makes entries on the nursing care plan. This assessment begins the admission process as well as gathers facts for discharge planning. It also individualizes the nursing care plan by adding comments pertinent to that particular patient. For example, a comment on chemical allergies would be noted on patient outcome standard 111, “Potential for impaired skin integrity, related to: allergic reactions to chemical agents.” The nurses conduct the outpatient teaching and interview program from 1 to 5 PM daily for adult preadmission processing and teaching. They show a videotape of the patient process through each area of OPSC and give a tour of the unit. We have a special videotape of the patient process for cataract patients who constitute a large percentage of our patient census. Nurses teach crutch walking for our arthroscopy patients and others who require it. This program aids in our documentation and discharge planning, particularly with elderly patients. At this time, we can ascertain the patient’s special needs for transportation, referrals to social services, or home health care. This aspect of patient care is reflected in outcome standard VI, “The patient participates in the rehabilitation process,” and is an important part of the total patient care effort.

OPSC Programs

Implementation

wo new programs demonstrate how our new forms aid in our preadmission program and in completing accurate, timely perioperative records. The pediatric preadmission program is held each Wednesday evening from 6 to 8 PM. We invite pediatric patients and their parents/or guardians to come to OPSC to complete their preadmission process. At this time, the OPSC staff conducts preoperative teaching, presents a slide show of the patient process through OPSC, and

ecause of revision and printing, time had elapsed since the last in-service program on the new perioperative record. A second in-service program was conducted for all staff members to thoroughly familiarize them with the records before putting them in use. The early morning in-service groups had begun charting on sample copies of records. This group consisted of primarily preoperative and operating room nurses. Pertinent patient information along with notations made by the nurse were already

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B

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JANUARY 1991, VOL.53, NO 1

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PATIENT CARE PLAN

Pmtlent's Name

Outpatient Surger, Center Directions Each unit. please check "Yes" or No" and in8tial oppropoate space tn mlumn on ngnt

Date

NURSING DIAGNOSES

PATIENT OUTCOME STANDARDS

GMI M1 .

I.

I. A Anxiety related lo knowledge dotun regarding surgical procedure B Fear related lo risk of death alteration of body Image Or change In Ihl0Sttyle C Impaired Verbal COmmunlCatlOn related 10 anxiety D Impaired verbal COmmunlCatiOn related to proPera1Ive msdlcat,o"/sedat,on E Impaired verbal commun~cationrelated to language barrier F lneflsctive individual or lamily coping related l o percelvad threat 01 surger, or surgical outcome G Noncompliance related 10 sensor,alteration lea: anxiety H Sensor,-perceptual alterallon related to inadequate tissue parfurion or pre-existing deIIcits

The patient demonstrates knowledge 01 the physloioglcai and psychological responws to surgical intervention

II.

II.

NO

Comments

~~

A

Potential lor inleCtiOn related l o Type 01 o p e r s t l ~procedure ~ Wound CIass~fication Tissues transected Length of piocedure Pra-existing disease P ~ C B D S Obesity Length 01 preoperative hospitalization Implants Presancelinsenian a1 InuasivelmJwellmg lines

The patient

13 tree

from lnleCtlOn

Yes

NO

Comments

~~~

111.

111. A

Potentla1 lor impaired Skcn lntegrlty related 10 POsltlOllng Pm-existing dtsease process Pooling of prep s o l ~ t l o nUnder ~ patient ImproDer Placement 01 electrical dispersive Pad Impaired ~ l r ~ ~ l a t l o n Poor 1lPS"e petfuslon Allergic reactionsto chemical agents

The patmf's skin integrity 1s maintained NO

Comments

I I

~

IV.

IV. Potential lor #"jury related to Electrical hazards Posltlonlng m i m e d forelgn object3 External constrictton of peripheral emulation Chemical agents IETO or Glutaraldehyde residuals irritants allergans) 0 Impaired gas exchange related to POSltlOnlng Inadequate airway Obesly C Impaired physical mobility related to positioning

The patient

A

free lrom inlur, related to

CommB n Is

I I I I

V.

V. A

IS

positioning extrsneo~sOblects or chemical physical and 0leCtriCal hazards

Ootentlal 10, lluld and electrOlyte imbalance related 10

Type 01 surgical procedure Excessiveblood loss Shock trauma

IS

The patients lluid and electrolyte balance maintained

NO

I I I I I

VI. A

Potential lor altered or ineffective paR~clpatiOnI" rehabilitation related to Inellectlve cop,ng mechanisms Anxiety due lo surgical outcomes Lack 01 resources lor sell care after discharge

P A T I E N T C A R E P L A N Y-OBC 12/90)

Fig 3. Patient care plan. 86

JANUARY 1991, VOL. 53,NO 1

AORN JOURNAL

OUTPATIENT SURGERY CENTER PACU NURSE'S NOTES

PT NAME

TIME IN

DATE

TIME OUT

Dyes OVes

ONo UNo

BREATH SOUNDS E Q U A L 8 CLEAR

SIDE RAILS UP

OYes O N 0

TEMP

PRE-OP BIP

MEDICATIONS

TIME

METH

T SIGNATURE

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P U L S

E

NOTES

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R E

S P I

R A

T I

0 N

I V INTAKE

OUTPUT

OTHER

TOTAL

V 4 6 A (Rev. 3/90)

Fig 4. The front page of the outpatient surgery center PACU nurse's notes. 88

JANUARY 1991, VOL. 53, NO 1

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OUTPATIENT SURGERY CENTER OBSERVATION NURSE’S NOTES

ARRIVAL TIME

IV

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OYes O N o

Site Edema Redness DC Time

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DRESSING. D y e s site

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0 Serous

Color

Signature

Serosanguinous

SIDE RAILS UP

OYes

0 No

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I

ONA

0 None 0 Mild 0 Moderate 0 Severe

0 Edges approximaled 0 NA 0 Dressing

I NAUSEA

yes

I WITH FAMILY

NO

I

Time -Name

I

PAIN.

Type--Amt--

Oyes

PRE-OP B/P

ON^

0 UP to Chair 0 Yes 0No

BP 2w

NOTES

180

1M 140 110

rm ml

M 4a

-: DISCHARGE )ISCHARGE TIME

TOLERATING FLUIDS OYes O N o

4LERT and ORIENTED

0 Yes

No

TOLERATING FOOD

OMild Drainage Scant TIME

METH

INT

1

OMod

0 Severe

OYes O N o O M o d OLarge

0 Serous 0 Serosanguinous DRAIN 0 NA 0 Dc d 0 Intact on

Color MEDICATIONS

0 Yes 0 No

WOUND

OEdges approximated NA

0 Dressing

Discharge

VOIDINGOYes O N 0 VERBALIZED AND DEMONSTRATED UNDERSTANDING OF DISCHARGE INSTRUCTIONS

OYes O N o

VITAL SIGNS CONSISTANT WITH PRE-OP LEVELS

MODE OF DISCHARGE

nW/C

OYes

0 No

OAmb OArms

Discharged with Oral IV

Emesis Urinary Other

Other TOTAL

TOTAL

POST-OPERATIVE TELEPHONE FOLLOW-UP 0 Yes 0 No Phone 0 No Answer Dale PAIN.

Time

-

0 Via ~ v Car t Escorted by Discharged to

0 Other OHome

mother

Signature

rEMP ELEVATION

OYes

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ONo ONo

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ONone

0 Mild

IIZZINESS

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0 Severe

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COMMENTS

__ Signature

Y-06A (Rev. 3/90]

Fig 5. The back page of the outpatient surgery center PACU nurse’s notes.

ck 89

JANUARY 1991, VOL. 53, NO I

AORN JOURNAL

on the record. The nurses divided into groups of four to complete the preoperative and operative portions of the record. They incorporated the patient care plan and added comments using the nursing diagnoses developed during their care of the patient. The afternoon in-service group, consisting of mainly postanesthesia care unit (PACU) and observation nurses then completed the records, adding their comments to the patient care plan. Finally, these sample records were audited to find discrepanciesor areas which might need clarification.

Conclusion

U

pdating nursing documentation is an ongoing process that reflects the expanding role of perioperative nurses. The challenge is to keep documentation thorough, yet not overly time consuming. Many surgical procedures in outpatient surgery are done in a short time on patients who have few if any health problems, yet some procedures are lengthy. More patients now, particularly the elderly, have multiple health problems and require early discharge planning. Documentation in all cases needs to be done quickly while still individualizing patient care and anticipating the needs of each patient during the perioperative process. Changing documentation is a lengthy, sometimes frustrating process, but it reflects nursing dedication in answering the increased demands of technology, the expanded role of perioperative nursing, the changing trends in medicine, and 0 accrediting requirements. Note 1. “Patient outcome standards for perioperative nursing,” in AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc., 1990) 115-1.

92

ANA Incorporates Credentialing Subsidiary Beginning Jan 1,1991, the American Nurses’ Association (ANA) will establish a separately incorporated center for credentialing services. The American Nurses Credentialing Center (ANCC) will aspire to meet nationally accepted standards to ensure the credibility of the credentialing process, clarify ANA’s role in setting standards, and act as a liaison to other nursing organizations and specialty certifying agencies, according to a news release from the ANA. The governing body of the ANCC will include members of the ANA board of directors. The center will base its credentialing programs on standards set by the ANA congress on nursing practice and will move toward meeting standards set by external credentialing agencies.

Cyclosporine May Not Be Cost-Effective Long-term use of cyclosporine after kidney transplantation is not cost-effective, according to an article in the Oct 10, 1990, issue of the Journal of the American Medical Association. The article describes a study of 203 kidney transplant recipients at the Institute for Health Policy Studies, San Francisco, studied. Results indicate that cyclosporine was associated with significantly better graft survival and lower costs during hospitalization. After discharge, however, the lower costs diminished substantially. The researchers conclude that cyclosporine may not be cost-effective for grafts that survive more than several months.