Debunking the Myths of PACU Nursing Documentation

Abstract

<h3>Background Information</h3> Weekly auditing of PACU documentation revealed inconsistencies in documentation practices among Post Anesthesia Care Unit (PACU) nurses. The individual preferences in documentation caused difficulty in retrieving data during chart review and auditing. Opportunities for standardizing documentation of nursing assessment, nursing care plan, medication administration and vital signs were identified in all PACU areas. The department identified the need to provide education on documentation accuracy, while regularly monitoring and evaluating documentation compliance. A decision was made to formulate a committee to standardize the auditing process, in order to sustain the compliance benchmark. <h3>Objectives of Project</h3> The goal of this project was to improve overall PACU documentation compliance by June 2021. The focus was to increase documentation compliance by 10% in the identified categories. The overall aim was to achieve documentation compliance of 90% in all PACU areas and have long-term sustainability. <h3>Process of Implementation</h3> •A PACU documentation committee was formed using Informatics Resource Nurses from inpatient, transitional, outpatient and out of OR PACU. The selection process involved self-nomination and leadership recommendation. •The documentation committee worked with the leadership team to develop unit-based reeducation and skills check-off to standardize documentation practices in all PACU areas. •A focused chart audit was created, and committee members conducted at least one audit per RN per month in all PACU areas. •A Peer-to-Peer Feedback Form was developed to provide real-time feedback and education to staff. •Chart Audit results were discussed in staff meetings with highlighted examples. <h3>Statement of Successful Practice</h3> •Data retrieved over the last 12 months showed significant improvement in standardizing PACU documentation and sustaining the documentation compliance above 90% in all areas. •Reeducation and skills check off helped standardize the practice and improved staff efficiency in documentation. •Review of the audit tool, guidelines for auditing and monthly meetings enhanced committee members' engagement and satisfaction. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> Streamlining documentation expectations can improve documentation practices and sustain compliance. Some best practices include: •Training new nurses during orientation with auditors to show documentation expectations. •Develop a checklist for Nurses to ensure complete documentation and use as a resource at bedside. •Reward best practice by recognizing 100% compliance in monthly audits.