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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
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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
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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 .
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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.
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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
.
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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.
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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,
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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 -
-
5/21/2018 A Guide to Revising PACU Documentation Record
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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