a guide to revising pacu documentation record

5/21/2018 A Guide to Revising PACU Documentation Record

1/9

amO m

Jab m Irm m- i n~ s

I L l L I B ~ 1 1 I b ~

G u i d e t o R e v i s i n g

t h e P o s t a n e s t h e s i a C a r e

U n i t D o c u m e n t a t i o n R e c o r d

S O P H I E R Y B A K RN

P A M B U S H BScN RN

T h e e n v i r o n m e n t o f th e P A C U i s c h a n g i n g r a p i d l y a s a re t h e s ta n d a r d s

p r o t o c o ls a n d r e q u i r e m e n t s o f d o c u m e n t a t i o n . N u r s i n g c a r e a c t i v i ti e s m u s t

b e c a p t u r e d in a t i m e l y a c c u r a te a n d e f f i c i e n t m a n n e r t h a t r e f l e c ts t h e

s t a n d a r d s o f c a r e a n d q u a l i t y p r a c t i ce w h i l e r e d u c i n g t h e a m o u n t o f a c t u a l

w r i t i ng r e qu i r e d . T h i s a r t i c l e r e v i e w s the av a i lab le l i t e r a tu r e and de f ine s a

p r o c e s s t o g u i d e o n e t h r o u g h t h e r e v i s io n o f a d o c u m e n t a t i o n r e c o rd .

9 1 9 9 9 b y A m e r i c a n S o c i e t y o f P e r i A n e s t h e s i a N u r s e s .

H E S T A F F o f a p r o g r e s s i v e P A C U i n a

7 0 0 - b e d t e r t i a r y c a r e C a n a d i a n a c a d e m i c

he a l th s c i e nc e s c e n te r r e c ogn iz e d tha t t he doc um e n-

t a t i o n r e c o r d h a d n o t k e p t p a c e w i t h t h e i r p r o f e s -

s iona l nu rs ing p ra c t i c e . The un i t s t a f f ha d a s t rong

q u a l it y i m p r o v e m e n t p h i l o so p h y . 1 T h e s h i ft t o

u n i t - b a s e d c o n t i n u o u s q u a l i t y i m p r o v e m e n t2 a nd

the imp le m e n ta t ion o f un i t c ounc i l s r e s u l t e d in the

d e v e l o p m e n t o f n e w s t a nd a r d s o f c a r e a n d t h e u n i t

s t a f f t a k ing a m ore a c t ive ro l e i n the c ha n ge

p roc e s s . Th e pu rp os e o f t h is a r t i c l e i s t o ou t l i ne the

p r o c e s s u s e d t o d e v e l o p a d o c u m e n t a t i o n r e c o r d

tha t s uppor t s p ro fe s s iona l nu rs ing p ra c t i c e a nd

a dhe re s to l e g i s l a t ive r e qu i re me n t s . In O n ta r io ,

p rov inc ia l l e g i s la t ive r e qu i re me n t s d i c t a t e t ha t e a c h

h o s p i t a l m u s t a d o p t a w o r k l o a d m e a s u r e m e n t t o o l

to a c c u ra t e ly r e f l e c t t he a c tua l pa t i e n t c a re hou rs

us e d by the hos p i t a l . Th i s doc ume n ta t ion re c o rd

fa c i l i t a te d c a p tu r ing the nu rs ing w ork loa d da ta .

The PA C U i s a 20 -be d un i t , p rov id ing c a re to a

w ide va r i e ty o f s u rg ic a l s pe c ia l i t i e s , e xc lud ing

pe d ia t r i c s , c a rd i a c s u rge ry , a nd ou tpa t i e n t s . The

a ve ra ge c e ns us i s 650 pa t i e n t s pe r mon th , w i th

l e n g t h s o f s t a y v a r y i n g f r o m 3 0 m i n u t e s t o 4 8

hours . The un i t a l s o func t ions a s t he c r i t i c a l c a re

ove r f low a re a w he n the in t e ns ive c a re un i t i s fu l l .

The PA C U i s s t a f fe d 24 hou rs a da y , 7 da ys a w e e k ,

s o le ly by p ro fe s s iona l r e g i s t e re d nu rs e s . The nu rs -

i n g s t a f f r e c o g n i z e d t h a t t h e d o c u m e n t a t i o n r e c o r d

w a s n o l o n g e r m e e t i n g t h e n e e d s o f t h e q u a l i t y -

foc us e d un i t , w h ic h ope ra t e d w i th in a p ro fe s s iona l

n u r s i n g p r a c ti c e m o d e l . T h e d o c u m e n t w a s a 1 - p a g e

re c o rd w i th the in t ra ope ra t ive a ne s the s i a r e c o rd on

t h e r e v e r s e s id e . T h e P A C U n u r s i n g s t a f f w a n t e d a

more u s e r - f r i e nd ly , a l l - i nc lu s ive doc ume n t tha t

re f l e c t e d the un i t s t a nda rds o f c a re a nd qua l i t y

p r a c t i c e , w h i l e r e d u c i n g t h e a m o u n t o f a c t u a l

w r i t i ng re qu i re d .

A s p a r t o f t h e q u a l i ty i m p r o v e m e n t p r o ce s s , t h e

d o c u m e n t a t i o n w a s r e v i e w e d , a n d m a n y i n c o n s i s -

t e nc ie s w e re found in the c ha r t ing me thods . S t a n -

da rd a bb re v ia t ions a nd de f in i t i ons w e re no t u s e d ,

Sophie Rybak, RN, is a Clinical Nurse and Pam Bush, BScN,

RN, is Clinical Services Manager at The Ottawa Hospital, Civic

Campus, Post Anaesthesia Care Unit, Ottawa, Ontario, Canada.

Address correspondence to Sophie Rybak, RN, The Ottawa

Hospital, Civic Campus, Post Anaesthesia Care Unit , 1053

Carling Ave, Ottawa, Ontario, Canada, KIY 4E9.

9 1999 by American Society o f PeriAnesthesia Nurses.

1089-9472/99/1405-0002503.00/0

Journa l o f PeriAnesthes ia Nurs ing Vo114, No 5 October), 1999: pp 251-259 251


2/9

5 R Y B A K A N D B U S H

re su l t i ng in a va r i e ty o f i n t e rp re t a t ions o f w ha t w a s

b e i n g d o c u m e n t e d . F o r e x a m p l e , p a i n w a s c h a r t e d

in the g ra ph ic s po r t i on o f t he o ld r e c o rd , a nd on e

m i g h t f i nd a c h e c k m a r k t o i n d i c a t e t h e p r e s e n c e o f

pa in o r a 0 t o i nd i c a t e t he a bse nc e o f pa in . Th i s

d i d n o t a l l o w a n o b j e c t i v e d e s c r i p ti o n o f t h e p a i n

in t e ns i ty t ha t i s ne c e ssa ry fo r t he a sse ssme n t o f

pa in a nd de t e rm ina t ion o f a na lge s i a e f fe c t. 3 A n-

o t h e r e x a m p l e w a s c h a r t i n g c o n t i n u o u s b l a d d e r

i r r i ga t ion a f t e r t r a nsu re th ra l r e se c t ion o f t he p ros -

t a t e g l a nd ; a c he c kma rk ind ic a t e d tha t t he p roc e -

d u r e w a s p e r f o r m e d b u t d i d n o t g i v e a d e s c r i p ti o n

o f t he re tu rn . U nusu a l b l e e d ing o r c lo t ti ng w a s

l a b o r i o u s l y d o c u m e n t e d i n t h e n u r s e s ' n o t e s .

U n i t s t a f f a l so r e c ogn iz e d tha t a c ha nge in t he

p a t i e n t c a r e d e l i v e r y s y s t e m w o u l d i m p a c t t h e

d o c u m e n t a t i o n r e q u ir e m e n t s . P r i m a r y n u r s i n g w a s

b e i n g i m p l e m e n t e d i n t h e P A C U a s t h e m o d e l o f

pa t i e n t c a re de l ive ry to e nsu re t ha t e a c h pa t i e n t

a d m i t t e d t o t h e u n i t w a s a s s i g n e d t o a p r i m a r y

nu rse d u r ing the t e nu re o f t he i r st a y. The p r im a ry

nu rse , i n c o l l a bo ra t ion w i th t he pa t i e n t , f a mi ly , a nd

o t h e r h e a l t h c a r e t e a m m e m b e r s , w a s r e s p o n s i b l e

fo r p l a nn ing , c oo rd ina t ing , a nd e va lua t ing the C a re

re c e ive d by the pa t i e n t . The ide n t i f i c a t ion o f t he

p r i m a r y n u r s e h a d t o b e i n c o r p o r a t e d i n t o t h e

d o c u m e n t a t i o n r e c o rd .

T h e P A C U s t a f f r e c o g n i z e d t h e n e e d t o d e v e l o p a

p r o g r e s s i v e , a l l - i n c l u s i v e d o c u m e n t a t i o n r e c o r d

tha t a c c u ra t e ly r e f l e c t e d the p ro fe ss iona l p ra c t i c e

a n d s t a n d a r d s o f c a r e . A s m a l l c o m m i t t e e o f 3

nu rse s w a s f o rm e d tO fa c i l i t a t e t he r e v i s ion a nd the

imp le me n ta t ion p roc e ss . The f i r s t s t e p w a s to

re v ie w the l i t e ra tu re fo r a r t i c l e s t ha t w ou ld gu ide

t h e c o m m i t t e e t h r o u g h t h e p r o c e s s .

LITERATURE REVIEW

In r e v i e w ing the l i t e ra tu re , a numbe r o f a r t i c l e s

w e re found re l a t e d to c r i t i c a l c a re a nd PA C U

doc um e n ta t ion , bu t t he f low she e t s p re se n te d in t he

l i t e ra tu re d id no t me e t t he i de n t i f i e d ne e ds o f t he

un i t . The re w a s no d i r e c t ion /p roc e ss ou t l i ne d to

gu ide the un i t t h rough the r e v i s ion . The re fo re , a

d e c i s io n w a s m a d e t o d e v e l o p a p r o c e s s t h a t m i g h t

se rve a s a gu ide l ine t o o the r s .

I y e r4 b r i e f ly ou t l i ne d a nu mb e r o f l e ga l i s sue s i n

r e l a t io n t o d o c u m e n t a t i o n , e m p h a s i z i n g t h e i m p o r -

t a nc e o f u s ing a u tho r i z e d a bb re v ia t ions a nd c ha r t -

i ng p rom pt ly . V o ig t e t a l3 s t r e sse d the impo r t a nc e o f

s t a n d a r d iz e d d o c u m e n t a t i o n o f p a i n a s s e s s m e n t .

T h e u s e o r a d d i t i o n o f a p a i n s c a l e w a s r e c o m -

m e n d e d t o i m p r o v e t h e a s s e s s m e n t o f p a in a n d t h e

e v a l u a t io n o f a n a lg e s i a. G r o e t h e 5 r e c o m m e n d e d

f l o w c h a r t i n g t o r e d u c e d o c u m e n t a t i o n t i m e a n d

ide n t i f ie d the ne e d fo r u t i l iz a t ion o f de f in i t ions . T he

l i t e ra tu re p rov ide d u se fu l i n fo rma t ion : how e ve r , i t

d id no t g ive d i r e c t ion to i n i t i a t e t he r e v i s ion

p roc e ss .

C o o p e r a ti o n a n d i n v o l v e m e n t f r o m a l l m e m b e r s

o f t h e P A C U t e a m w e r e e s s e n ti a l t o s u c c e s s fu l l y

d e v e l o p a n d i m p l e m e n t a n e w d o c u m e n t a t i o n r e c -

o rd . Th i s w a s c on f i rm e d by A l l a n , 6 w ho s t r e sse d the

i m p o r t a n c e o f i n v o lv i n g n u r s e s i n t h e c h a n g e

p roc e ss a nd the i r ne e d to c r i t i c a l ly e va lua t e t he i r

n u r s i n g p r a c t i c e . T h e P A C U n u r s e s w e r e i n c r e a s -

i n g l y i n v o l v e d i n p a r t i c i p a t i v e d e c i s i o n - m a k i n g

re l a t e d to pa t i e n t c a re , nu r s ing p ra c t i c e , a nd o the r

p ro fe ss iona l i s sue s . The re w a s s t rong suppor t fo r

re v i s ing the doc ume n ta t ion r e c o rd , be c a use i t w a s

e v ide n t t ha t t he c u r re n t r e c o rd no longe r me t t he

ne e ds o f t he un i t , bu t i t be c a me c l e a r t ha t t h i s

w o u l d b e a l o n g a n d i n v o l v e d p r oc e s s .

INFORMATION GATHERING

A fte r t he l i t e ra tu re r e v i e w , t he ne x t t a sk o f t he

c o m m i t t e e w a s t o g a t h e r i n f o r m a t i o n . M o r e t h a n

h a l f o f t h e 1 8 te a c h i n g h o s p i t al s o f c o m p a r a b l e s i z e

a c r o s s C a n a d a w h o w e r e c o n t a c t e d p r o v i d e d c o p ie s

o f t h e ir P A C U d o c u m e n t a t io n r e c o r d s . T h e r e c o r d s

r a n g e d i n l e n g t h f r o m 1 t o 4 p a g e s . M o s t r e c o r d s

w e r e a c o m b i n a t i o n o f f lo w c h a r t s a n d n a r r a t i v e

n o t es . M a n y i n c o r p o r at e d a p o s t a n e s t h e ti c r e c o v e r y

sc o re i n to t he i r r e c o rd . Min ima l u se o f de f in i t i ons

t o e n c o u r a g e s t a n d a r d i z at i o n o f d o c u m e n t a t io n w a s

found . Th i s i n fo rma t ion w a s sha re d w i th a l l t he

o t h e r P A C U n u r s e s , a n d f e e d b a c k w a s s o l i c i t e d

f r o m t h e m t o d e t e r m i n e w h i c h f e a t u r e s o f th e p e e r

re c o rds a s w e l l a s a ny o the r c ha ra c t e r i s t i c s t he y

w ishe d to i nc o rpo ra t e i n to t he ne w re c o rd .

O v e r t h e c o u r s e o f t h e r e v i s i o n , a f o r m a l p r o c e s s

e vo lve d (Ta b le 1 ) . Th i s p roc e ss w a s u se d to gu ide

t h e c o m m i t t e e . C o m m i t t e e m e m b e r s a s s i s t e d t h e

s t a f f t o d e v e l o p a n d p r i o r i t iz e o b j e c t iv e s e m p h a s i z -

ing the i n t e rna l a nd e x t e rna l va r i a b l e s a f fe c t ing the

d o c u m e n t a t i o n r e c o r d . O b j e c t i v e s w e r e e s t a b l i s h e d

to de ve lop a f l ow she e t t ha t no t on ly c o l l e c t e d

c l in i c a l da ta , bu t a l so w a s suppo r t ive o f t he qua l i ty

i m p r o v e m e n t a c t i v it i es , p r o f e s s i o n a l n u r s i n g p r a c -

t i c e mode l , a nd l e g i s l a t i ve c ha nge s .

T h e P A C U s t a f f w a s a c t i v e l y i n v o l v e d in t h e

O n t a r i o P o s t A n a e s t h e t ic N u r s e s A s s o c i a t i o n a n d

fe l t s t rong ly tha t t he S t a nda rds o f Pos t A na e s the s i a


3/9

R E V I S I N G T H E P A CU D O C U M E N T A T I O N R E C O R D 53

T a b l e 1 . P r o c e s s f o r R e v is i n g a D o c u m e n t a t i o n R e c o r d

1 . E s t a b l i sh a sm a l l , u n i t - b a se d co m m i t t e e .

2 . D e ve l o p a c r i ti ca l p a t h w i t h re a l i s t i c t i m e f ra m e s .

3 . R e v i e w t h e a va i l a b le l i te ra t u re a n d g a t h e r i n f o rm a t i o n

f ro m p e e r h o sp i t a l s .

4 . D e t e rm i n e o b j e c t i ve s a n d s e t p r i o r i t ie s f o r t h e r e v i s i o n

ke e p i n g i n m i n d a n y i n t e rn a l a n d e x t e rn a l f a c t o rs t h a t

m a y i m P a c t o n t h e re co rd .

5 . D e t e r m i n e a m e t h o d o f c o m m u n i c a t i n g i n f o r m a t i o n

a n d g a t h e r i n g i n p u t f r o m U n i t s t a f f a n d t h e D e p a r t m e n t

o f A n e s t h e s i o l o g y .

6 . D ra f t se ve ra l p o t e n t a l d o cu m e n t a t i o n r e c o r d s f o r

r e v i e w by Staff .

7 . S u b m i t f in a l d ra f t f o r p r i n t in g .

8 . Fo l l o w yo u r h o sp i t a p o l i cy re g a rd i n g su b m i ss i o n t o

t h e F o r m s C o m m i t t e e fo r a p p r o v a l .

9 . D e v e l o p a u d i t to o l s t o d e t e r m i n e w h e t h e r t h e d o c u -

m e n t a t i o n re co rd m e t t h e o b j e c t i ve s i d e n t i f ie d i n s t e p 4 .

10 . Edu cate the PACU and surg ica l nurs ing u n i t s ta f f .

1 1 . P i l o t t h e n e w re co rd .

1 2 . E va l u a t e t h e re co rd u s i n g a u d i t t o o l s , a n d re v i se a s

n e ce ssa ry .

N u r s i n g P r a c t ic e 7 m u s t b e a d h e r e d t o a n d b e

e v i d e n t i n t h e i r d o c u m e n t a t i o n . T h e c o m m i t t e e

the re fo re ha d to be c ogn iz a n t o f t he se s t a nda rds

du r ing the r e v i s ion p roc e ss .

The PA C U ha d a ve ry a c t ive C on t inuous qua l i t y

i m p r o v e m e n t c o m m i t t e e , w h i c h r e v i e w e d a n d d e -

ve lop e d s t a nda rds o f c a re fo r t he un it . The c o n t inu -

o u s q u a l i ty i m p r o v e m e n t c o m m i t t e e h a d r e c e n tl y

d e v e l o p e d s t a n d a r d s f o r p u l s e o x i m e t r y m o n i t o r -

i n g , t e m p e r a t u r e m o n i t o ri n g , a n d b l o o d p r e s s u r e b y

a usc u l t a t ion . Th i s c o mm i t t e e r e que s t e d tha t the

d o c u m e n t a t i o n r e c o r d r e f l e c t t h e s e n e w l y d e v e l -

ope d s t a nda rds .

T h e d o c u m e n t a t i o n c o m m i t t e e w a s d e l i n e a t i n g

t h e o b j e c ti v e s , w h i l e p r i m a r y n u r s i n g w a s b e i n g

in t roduc e d in to t he PA C U . Th i s pa t i e n t c a re de l iv -

e r y s y s t e m a s s i g ns a p r i m a r y n u r s e t o d e v e l o p a

p l a n o f c a r e f o r t h e p a t i e n t f r o m a d m i s s i o n t o t h e

PA C U un t i l t he t ime o f d i sc ha rge . I w a s the goa l o f

t h e u n i t - b a se d p r i m a r y n u r s i n g c o m m i t t e e t o e n s u r e

t h a t t h e k e y p r i n c i p le s o f p r i m a r y n u r s i n g 8 w e r e

m e t i n t h e d o c u m e n t a t i o n r e c o r d . T h e p r i m a r y

n u r s i n g c o m m i t t e e w a n t e d t o f a ci l it a t e c o m m u n i c a -

t i on a nd a c c oun ta b i l i t y . Spa c e w a s inc lude d on the

re c o rd to i nd i c a t e t he p r ima ry a nd a ssoc i a t e nu r se s

fo r t he pa t i e n t . A se c t ion w a s p rov ide d fo r t he

p r ima ry nu r se t o d .e ve lop a c a re p l a n a s ne e de d .

I n c l u d e d i n t h e g r a p h i c p o r t i0 n o f t h e d o c u m e n t a -

t i on r e c o rd w a s a n a re a fo r t he nu r s ing s t a f f t o

in i ti a l t o ind i c a t e t he g iv ing a nd re c e iv ing o f ve rba l

re po r t s .

I t w a s a n t i c i p a te d t h a t t h e p e n d i n g i m p l e m e n t a -

t io n o f t he w o r k l o a d m e a s u r e m e n t t o o l w o u l d h a v e

a n i m p a c t o n t h e r e c o rd . I n v i e w o f t h is , t h e

r e v i s i o n o f t h e d o c u m e n t a t i o n r e c o r d w a s p u t o n

h o l d . A f t e r t h e i m p l e m e n t a t i o n o f t h e w o r k l o a d

m e a s u r e m e n t t o o l , a n u m b e r o f p a t ie n t c a r e a c t i vi -

t i e s w e re i de n t i f i e d tha t w e re rou t ine ly pe r fo rme d

b u t n o t d o c u m e n t e d o n t h e o l d r e c o r d . S o m e

e x a m p l e s w e r e m o u t h c a r e . r e p o s it i o n in g , r e a p p l i -

c a t ion o f w a rm b la nke t s , a nd re po r t ing a c t iv i ty

b e t w e e n n u r s e s. T h e c o m m i t t e e w a n t e d t o i n c o r p o -

ra t e a l l o f t he se a c t iv i t i e s i n to t he ne w re c o rd .

T h e P A C U n u r s i n g s t a f f t o o k t h i s o p p o r t u n i t y

to e xa mine c u r re n t d i sc ha rge p ra c t i c e s i n o the r

PA C U s. The d i sc ha rge c r i t e r i a a nd sc o r ing tha t

w e r e i n u s e w e r e r e v i e w e d , a n d i t w a s d e t e r m i n e d

tha t t he y d id no t m e e t t he ne e ds o f t he un i t. The

typ ic a l d i sc ha rge sc o r ing sys t e m inc lude d a sub je c -

t i v e a s s e s s m e n t o f c o l o r b u t d i d n o t i n c l u d e o x y g e n

sa tu ra t ion , t e mpe ra tu re , pa in , na use a , a nd vomi t -

i n g. T h e n u r s i n g s t a f f w a n t e d m o r e p r o g r e s s i v e

d i sc ha rge c r i t e r i a t ha t r e f l e c t e d the s t a nda rds o f

c a re p rov ide d . A f t e r c onsu l t a t i on w i th t he Me d ic a l

D i r e c t o r o f t h e P A C U , a n o b j e c t i v e r e c o v e r y s c o r e

a n d d i s c h a r g e c r i t e r i a w e r e d e v e l o p e d . T h e n e w

r e c o v e r y s c o r e i n c l u d e d a n a s s e s s m e n t o f o x y g e n

sa tu ra t ion r a the r t ha n c o lo r . Te mpe ra tu re w a s in -

c l u d e d t o e m p h a s i z e t h e i m p o r t a n c e o f n o r m o t h e r -

m i a o n p a t i en t r e c o v e r y . A s t a n d a r d i z e d a s s e s s m e n t

o f p a i n u s i n g a v e r b a l n u m e r i c a l s c o r e w a s i n -

c lude d , a s w e l l a s a sc o r ing sys t e m fo r na use a /

vomi t ing . Th i s r e c ove ry sc o re i s i nc lude d in t he

g r a p h i c p o r t i o n o f t h e d o c u m e n t a t i o n r e c o r d .

W i t h t h e w o r k l o a d m e a s u r e m e n t s y s t e m a n d

p r i m a r y n u r s i n g w e l l u n d e r w a y , t h e c o m m i t t e e

r e s u m e d t h e t a s k o f r e v i s i n g a n d d r a f t i n g t h e P A C U

re c o rd . A se r i e s o f d ra f t s w e re de ve lope d a nd

s h a r e d w i th t h e P A C U t e a m a n d t h e D e p a r t m e n t o f

A n a e s t h es i a . F e e d b a c k w a s o b t a i n e d a n d r e v i s io n s

m a d e . T h e r e s u lt i n g 4 - p a g e re c o r d F i g 1 ) w a s t h e n

s e n t to t h e D e p a r t m e n t o f R e p r o g r a p h i c s f o r t y p e -

se t t i ng a nd l a se r p r in t ing . A t t h i s po in t , i t w a s e a sy

to move se gme n t s t o f a c i l i t a t e t he f l ow o f t he

d o c u m e n t a n d t o m a k e c h a n g e s s u g g e s t e d b y t h e

p r in t e r . The f ina l d ra f t w a s a ga in sha re d w i th t he

D e p a r t m e n t o f A n a e s t h e s i a a n d t h e D i r e c t o r o f

N u r s i n g f o r t h e i r i n p u t . T h e n e w d o c u m e n t a t i o n

r e c o r d w a s t h e n s u b m i t t e d t o t h e H o s p i t a l F o r m s

C o m m i t t e e f o r r e v i e w a n d a p p r o v a l .


4/9

54 R Y B K N D B U S H

OTTAWACiViC HOSPITAL

POST N ESTHESI C RE UNIT RECORD

Date:

Procedure:

Reporting Anaesthetist:

Primary Nurse:

Associate Nurse(s):

Time: From:

IntitaL

Initial:

Position of Patient:

[] Left ateral [] Right lateral [] Supine

Type of Anaesthetic:

[] General [] Spinal [] Epidural [] Local

D Other

Airway:

[] None [] Endotracheal [] Nasotracheal

[] Oralpharyngeal [] Nasopharyngeal

Removed @ __ .h ou rs Removed by

Oxygen:

[] None required [] Mask [] Nasal Prongs

[] Ven imask [] Non-Rebreathing Mask

02 @ 1/min Fi02 @ %

Ventilator Assist:

ventilator type [] SIMV

Rate /min Fi02 % TV __

[] Semi Fowlers

]

HOB @ degrees

[] Regional [] IV Conscious Sedation

[] Laryngeal Mask [] Trachenstomy

[] T-piece [] Trach Hood

[] Assist/Control O CPAP

PEEP PS__

Equipment:

[] Pulse Oximeter

[] EKG Monitor; Rhythm

CI Arterial line [ ] ft. side Cl it. side

[] CVP line [] rt, side [] It, side

[] PA catheter [] rt. side [] It. side

[] Epidural; site

[] CPM @ degrees

[] Traction; site

[] Forced Air Warming System

[] Other

Surgica Site:

#1 Location Type Condition

#2 Location Type Condition

[] Peripad drainage

Drains, etc.:

[ ] Hemovac x , s ite [ ] Fo ley cathe ter; d rainage _ _ [ ] NG tube to

[] Jackson Pratt x . site [] Suprapubic catheter; [] Irrigations; type

[] Penrose; site drainage Return

[] Chest tube x @ cm H20 suction [ ] I leoconduit ; drainage _ _ [ ] Cast; condi tion

[] Fluctuation [ ] Bubbling [] Nephrostomy: [] rt. [] It, [] Packing; site

[ ] C o lo s to m y /I le o st o m y s to ma d ra in ag e _ _ [ ] O th er :

suction

Comments on Admission:

Primary Nursing Plan of Care:

[] I.D, Check x4)

Signature of Admitting Nurse RN

[] Dr. OrdersChecked x2)

Fig 1. Ott awa Civic Hospital Post Anaesthesia Care Unit Record. Reprinted w ith permission from t he Civic Campus of the Ott awa

Hospital, Ot tawa , Ontario, Canada.


5/9

R E V I S I N G T H E P C U D O C U M E N T T I O N R E C O R D

255

RECOVERY SCORE:

Level of Consciousness: 02 Saturation: Respiration:

2 Awake 2 Sp02>- 2 on room air 2 Able o deep breath & cough

1 Drowsy 1 Sp02->92 on oxygen 1 Limited breathing

0 Unconscious 0 Sp02< 92 on oxygen 0 Requires irway support

Circulation: Temperature: Nausea & Vomiting:

2 BP+ 20 otpre-op 2 _>360C 2 Controlled

1 BP + >20 ~ 40 of pre-op t -> 34 5 C < 30 C 1 Further reatment equired

0 BP+ >40 otpre-op 0 < 34.5C g Uncontrolled

Pain:

2 Controlled 1 Further reatment equired 0 Uncontrolled

Level of Consciousness

Circulation

Respiration

02 Saturation

Temperature

Nausea & Vomiting

Pain

Total Score

Blood 220

Pressure 210

20O

190

v

(cuff)

t

^ 170

160

150

v

I

140

(monitor) I 130

I 120

A 110

100

Pulse 9 90

80

70

6O

50

40

30

Resp. Rate

Oxygen

02 Sat

Temp

Warm Blankets

DB&C

Pain Scale

Nausea Vomiting

Mouth Care

Surgical Site

Peripad

Irrigations

Turn Position

Sensory Block

Motor Block

Pulse rt

Pulse R.

Verbal Response

Pupils

Arm Stmnglh

Leg Btrenglh

Reassured

Report Given

Report Received

Initials

' ' ~! PRE-OP:

l i l t

I l l l l

I I I I I

I I I I I

I I I l l

I l f l l

I IHI

I l i l ~

I l f l l

J i l l

a l i b i

l l l l

I I I I

I I I 1~

I l i l

I I I l l

l i l l ~

I l i l

I I I I i

I I I 1~

4S 0 ~ so ~s o i~ 3o

iliRilHl

i i i i i i i l i

i i i i i i i i

iiiiiii u ri u

i i i i i i i n l i nmml l

f l i l l l l ~ l l i i l l l

. . . . . . . ~ l l O l l l l

i i i i i i i H i t i i i n l

. . . . . . . ~ l l i l l g l

: : : : : : : : " ' ' l l l g l

i i i i i i i ; ; i ~ ; i ; i

: : : : : : : : I I I I l l I g l

i i i J i i i i i i i i i i i i

l i H i i H i U I I H I I H I

[ :~ [ : : : ~ l l l l l i l

T _ _ B P_ _ P _ _ R _ _

15 ~ ~S IS

Hli l i

;I

IIID III

II11 III

~IIM ~ III

Illll HI

I [ IH HI

~IIN HI

, I ,n Ni

; : : : :

Ul

i i i i N i

h i ,

i i i i i i I I

II

. . . . . . II

I I

II

i iJi i nl

I l i l | I I

i i i i i n l

I l l l HI

J llt

: : : : : : : : :

N mill

. . . . . . . . . . . . . I l l: : : : : : : : i

I I

: : ; : : : : : :

. . . . . . . . . . i l

: : : : ; ; :

I

l i l

: : : : : : : :

l i U

ii iiiJ I n

l g l l l i l i

~ J J i i J i i i i t

i

i i i J i i H i i t i t B

F ig 1 (c o n t ' d ) . O t ta wa C iv i c

H o s p i ta l P o s t A n a e s t h e s i a

Ca re Un i t Re c o rd . Re p r in te d w i th p e rm is s io n f ro m th e C iv i c Ca mp u s o f th e

Ot ta wa Ho s p i ta l , O t ta wa , On ta r io , Ca n a d a .


6/9

2 5 6

Time Medication Dose Route Signature Initial

R Y B K N D B U S H

Allergies: [] NKDA

Medication Time

Dose

Init

Medication Time

Dose

Inil

[] IV/Epidural PCA

[] Dressing at site changed. Initials

[ ] EKG @ _ _ hours

RN

Medication Time

Dose

Init

started at hours. Please see PCA Medicati on Administra tion Record.

[] Epidural checked as per protocol. Initials RN

[ ] X -ra y: ty pe : @ _ _ h ou rs

Volume Time Down/ Volume

Time Up Solution Additive TBA Site to Ward Infused Time Source s)

Volume

Total ntake (mls) TotalOutput (mls)

Time FiO2 13H pOO~ p02 HC03 B.E O~Sat Vf Rate PEEP PS RR Time WBC Hgb Hc~ PIt INR PTT

Time Na K CI Glu Ur Cr Ca CPK lime

Date: Time: To:

Comments on Discharge:

Discharged by: RN Patient left unit al hours

Fig 1 (cont d). Otta wa Civic Hospital Post Anaesthesia Care Unit Record. Reprinted with permission from the Civic Campus of the

Ottawa Hospital, Ottawa, Ontario, Canada.


7/9

R E V I S I N G T H E P C U D O C U M E N T T I O N R E C O R D

57

L EEr - ,n o .

Oerl

Motor Block Scale:

O. None moves knees, eet and hips.

1. Partial able o bend knees.

2. Complete does not move eel or knees

Surgical Site:

D Dry

So Scant amoun

Sm Sma amount

M Moderate mount

LG Large amount

PainScale:

0-3 Miid Pain

3-7 Mode~le

7-10 Sovem

Puripad:

D Dr/

S Scanl

mount

(< 1

nch

stain)

L Light amount (>1 , 4,


8/9

258 R Y B A K A N D B U S H

ED U C A T IO N , P ILOT, A N D FEED BA C K

O n c e t h e d r a f t d o c u m e n t a t i o n r e c o r d w a s r e -

c e i v e d f r o m R e p r o g r a p h i c s , g u i d e li n e s w e r e d e v e l -

o p e d t o f a c i l i ta t e t h e c o m p l e t i o n o f t h e n e w d o c u -

m e n t a t i o n r e c o r d . T h e c o m m i t t e e m e m b e r s

u n d e r t o o k o n e - o n - o n e e d u c a t i o n o f t h e 2 8 P A C U

sta f f nu r se s t o r e v i e w the r a t i ona l e a nd p r inc ip l e s

b e h i n d t h e n e w d o c u m e n t a t i o n r e c o r d , a s w e l l a s

p r o p e r d o c u m e n t a t i o n p r o c e d u r e s . T h i s p r o c e s s

t o o k a p p r o x i m a t e l y 1 m o n t h t o c o m p l e t e .

A n imp le me n ta t ion da t e w a s se t t o d i s t r i bu t e t he

n e w r e c o r d a n d b e g i n i t s u se . T h i s i n f o r m a t i o n w a s

c o m m u n i c a t e d t h r o u g h m e m o s t o a ll n u r s in g u n i ts

b e f o r e i m p l e m e n t a t i o n . T h e c l i n i c a l n u r s e e d u c a -

to r s a ss igne d to t he su rg i c a l nu r s ing un i t s a ssume d

re spons ib i l i t y fo r i n fo rmin g the i r s t a f f a bou t t he

re c o rd a nd i t s i n t e rp re t a t i on . A p i lo t o f 3 t o 4

m o n t h s w a s p l an n e d f o r t he P A C U n u rs e s to

b e c o m e f a m i l i a r a n d c o m f o r t a b l e w i t h t h e n e w

r e c o r d . T h i s w o u l d a l s o a l l o w e n o u g h t i m e t o

d e t e r m i n e a n y n e c e s s a r y i m p r o v e m e n t s o r d e l e -

t i ons t ha t w ou ld be r e qu i re d to t he p i lo t r e c o rd

be fo re t he a n t i c ipa t e d f ina l p r in t ing .

D ur ing the p i lo t pha se , a b inde r w a s p r ov ide d fo r

P A C U s t a f f a n d a n e s t h e s i a s t a f f t o c o m m u n i c a t e

a n y c o m m e n t s , c o n c e r n s , c o n s t r u c t i v e c r i t i c i s m s ,

a n d s u g g e s t i o n s f o r i m p r o v e m e n t , w i t h t h e i n t e nt t o

re v ie w the se a t t he e nd o f t he p i lo t pha se . The

c o m m e n t s w e r e t a k e n i n t o c o n s i d e r a t i o n w h i l e

re v i s ing the doc ume n ta t ion r e c o rd .

EV LU T ION

To e va lua t e t he nu r s ing p ra c t i c e a nd s t a nda rds ,

a u d i t t o o l s w e r e d e v e l o p e d . F o r e x a m p l e , t h e

s t a n d a rd f o r m o n i t o r i n g o f b l o o d p r e s s u r e s b y

a usc u l t a t i on w a s a ud i t e d w i th bo th the o ld a nd ne w

r e c o r d s. T h e r e v i s e d s t a n d a rd o f c a r e f o r b l o o d

p r e s s u r e m o n i t o r i n g r e q u i r e s c o m b i n a t i o n b l o o d

pre ssu re s by a usc u l t a t i on a nd pa lpa t ion r a the r t ha n

t h e p a s t p r a c t i c e o f b l o o d p r e s s u r e b y p a l p a t i o n

o n ly . A n i n c r ea s e i n c o m p l i a n c e b y 2 0 w a s f o u n d

w i th the ne w re c o rd .

T h e p r o v i s i o n o f d e f i n it i on s o n t h e d o c u m e n t a -

t i o n r e c o rd h a s h e l p e d e n s u r e c o n s i s t e n c y i n d o c u -

m e n t a t i o n p r a c t i c e s . F o r e x a m p l e , a v e r b a l p a i n

sc a l e ha s be e n inc o rpo ra t e d in to t he g ra ph ic po r t i on

o f t he ne w re c o rd to s t a nda rd i z e pa in a sse ssme n t . A

de f in i t i on ha s a l so be e n de ve lope d to de sc r ibe the

re tu rn o f i r r i ga t ion f lu id by u s ing a s imp le c od e tha t

i s c ha r t e d unde r I r r i ga t ions i n t he g ra ph ic se c t ion o f

the ne w re c o rd , u s ing the c ode s p rov ide d in t he

l e ge nd unde r B la dde r I r r i ga t ions . Th i s ha s r e duc e d

d o c u m e n t a t i o n t i m e a n d i m p r o v e d c o n s i s t e n c y i n

c ha r t i ng . The a ud i t p roc e ss ha s c on f i rme d the se

f indings.

T h e P A C U P r i m a r y N u r s i n g C o m m i t t e e d e v e l -

ope d a n a ud i t t oo l t o mon i to r c on t inu i ty o f c a re

b a s e d o n t h e n e w d o c u m e n t a t i o n r e c o rd . T h i s a u d i t

i s in p rog re ss , a n d i t a ppe a r s t ha t t he r e v i se d r e c o rd

suppor t s c on t inu i ty o f c a re , spe c i f i c a l ly th rough the

u s e o f t h e ca r e p la n . S o m e e x a m p l e s o f w h a t m i g h t

be inc lude d in t he c a re p l a n inc lude spe c i a l ne e ds o f

the pa t i e n t ( i e , pos i t i on ing , p ro s the t i c de v ic e s ,

l a ngua ge in t e rp re t a t i on ne e ds , spe c i f i c c u l tu ra l

ne e ds) a nd the a c tua l p l a n o f c a re fo r t he pa t ie n t .

T h e n e w d o c u m e n t a t i o n r e c o r d m o r e a c c u r a t e l y

re f l e c t s t he c a re be ing p rov ide d . Th i s ha s be e n

c on f i rme d by a n inc re a se i n t he pa t i e n t c a re hou rs

i d e n t i f i e d i n t h e w o r k l o a d m e a s u r e m e n t s y s t e m

a f t er i m p l e m e n t a t i o n o f t h e n e w d o c u m e n t a t i o n

re c o rd . F ina l ly , t he c ha r t i ng t ime ha s be e n re duc e d

b y d e c r e a s i n g t h e a m o u n t o f h a n d w r i tt e n i n f o r m a -

t ion a nd re p l a c ing i t w i th s t a nda rd i z e d , ob j e c t ive

f low c ha r ti ng , w h i l e me e t ing l e ga l r e qu i re me n t s .

S U M M R Y

T h e r e v i s io n o f t h e d o c u m e n t a t i o n r e c o r d h a s

p r o v i d e d t h e c o m m i t t e e w i t h a n o p p o r t u n i t y t o

l e a rn a bou t t he c ha nge p roc e ss a nd the c ha l l e nge o f

w o r k i n g w i t h l a r g e g r o u p s. O v e r t h e c o u r s e o f t h e

re v i s ion , a fo rma l p roc e ss e v o lve d (Ta b le 1 ), w h ic h

w a s u s e d t o g u i d e t h e c o m m i t t e e . T h e p r o c e s s t h a t

w a s f o l l o w e d h a s r e s u lt e d i n a p r o g r e s s i v e m o d e r n

d o c u m e n t a t i o n r e c o r d u n l i k e a n y o f t h o s e p r o v i d e d

by pe e r hosp i t a l s o r pub l i she d in t he l i t e ra tu re .

A s a p r o f e s s i o n a l s t a f f i n v o l v e d i n d e c i s io n

m a k i n g a n d s e e k i n g a c c o u n t a b i l i ty a n d a u t o n o m y ,

t h e r e w a s n o q u e s t i o n t h a t t h e P A C U t e a m h a d t o

pa r t i c ipa t e i n t he r e v i s ion p roc e ss . The PA C U

nurse s i de n t i f i e d the ne e d fo r a p rog re ss ive doc u -

me n ta t ion r e c o rd tha t a c c u ra t e ly r e f l e c t e d the h igh -

q u a l it y c a r e p r o v i d e d i n th e P A C U . T h e c o m m i t t e e

f a c il i ta t e d th e d e v e l o p m e n t a n d i m p l e m e n t a t i o n o f

the r e v i s ion .

The a spe c t s o f t he p roc e ss t ha t w e re pa r t i c u l a r ly

impor t a n t w e re t he de t e rmina t ion a nd se t t i ng o f

p r io r i t i e s fo r t he r e v i s ion , ke e p ing in mind a ny

in t e rna l a nd e x t e rna l f a c to r s t ha t impa c t on the

r e c o r d . E n s u r i n g o p e n c o m m u n i c a t i o n a m o n g t h e

P A C U a n d D e p a r t m e n t o f A n a e s t h e s i a s t a ff f o s -


9/9

R E V I S I N G T H E P A C U D O C U M E N T A T I O N R E C O R D 59

t e r e d p a r ti c i p a ti o n i n th e p r o c e s s a n d a c c e p t a n c e o f

t h e f i n a l p r o d u c t .

I n r e t ro s p e c t t h is p r o c e ss w o u l d h a v e b e e n

f a c i li t a te d b y h a v i n g a s l ig h t l y l a rg e r c o m m i t t e e o f

4 t o 5 m e m b e r s t o g a th e r a n d d i s s e m i n a t e i n f o r m a -

t i o n t o t h e s t a f f . A c r i t i c a l p a t h w i t h d e f i n e d t i m e

f r a m e s a n d a r e s p o n s i b l e p e r s o n i d e n t i f ie d w o u l d

h a v e p r o v i d e d a ta r g e t a n d m a y h a v e h e l p e d t o k e e p

t h e p r o j e ct f o c u s e d . K e e p i n m i n d t h a t a m a j o r

r e v i s i o n o f a d o c u m e n t a t i o n r e c o r d c a n b e a 1 - t o

2 - y e a r p r o c e s s a n d th a t s o m e o b s t a c l e s m a y b e

e n c o u n t e r e d a l o n g t h e w a y . O n e o f th e g r e a t e s t

o b s t a c l e s w a s c o m i n g t o c o n s e n s u s o n w h a t s h o u l d

b e i n c l u d e d o r e x c l u d e d f r o m t h e r e co r d .

ACKNOWLEDGMENT

The authors thank Dr Jo Logan PhD RN Assistant Profes-

sor Faculty of Health Sciences University of Ottawa and

Kathleen Graham MN RN Clinical Director Su rgical Portfo-

lio the Ottawa Hospital Civ ic Campus for their encourage-

ment support and valuable expertise in the development of this

article. The development o f the documentation record w ould not

have been possible without the enthusiasm expertise and

participation of the clinical nursing staff in the PACU of the

Ottawa Hospital Civ ic Campus.

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2. Matthals SM Greenlee KK: Develo ping unit specific

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3. Voigt L Palce JA Pouliot J: Standardized pain flowsheet:

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4. Iyer P: Thirteen charting rules to keep you legally safe.

Nursing 91:40-45 1991

5. Groethe E: Documentation in critical care: A flow sheet

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6. Allan D: Bedside charts: How to introduce change. Nuts

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a guide to revising pacu documentation record

Documents