Pitfalls in Perioperative Documentation, Compliance with the EMR

Abstract

<h3>Background Information</h3> In 2018, Perianesthesia nurses at Delnor Hospital embarked on a documentation quality improvement initiative. A team of nurses collaborated to promote consistency in standardized documentation within The American Society of Perianesthesia Nurses (ASPAN) guidelines by enhancing electronic documentation. A workgroup was developed with representation from Pre-op, Phase I, Phase II, Professional Development, and Perioperative Leadership with both surgical areas within Delnor. The team established documentation guidelines based ASPAN standards. Education was developed along with an audit tool to measure compliance. Baseline data from the start of the project in 2018 identified documentation compliance was less than 62% for all areas. A goal was established to improve compliance to 85%. After three months of audits, all three areas achieved the goal and exhibited significant improvement. With continued audits and peer coaching provided by the documentation committee compliance was achieved. However, after the pandemic hit sustainment of the goal decreased in compliance. <h3>Objectives of Project</h3> The committee focused on reeducation of the team and audits to reestablish the expectation, hold staff accountable and get back to the targeted goal. <h3>Process of Implementation</h3> A pre-learning audit was completed to determine baseline data and where reeducation was needed. The education was disseminated to the staff in the three phases of care. The documentation guidelines and education were added to the orientation binder for new staff. Twenty audits were completed monthly per area for three consecutive months. The re-introduction of the project was received positively and the staff felt empowered with knowledge, increased confidence on appropriate assessment/documentation, and improved communication through the Perioperative setting. It was identified that staff who were non-compliant, were the ones who were resistant to the initial project and fell back to old habits. <h3>Statement of Successful Practice</h3> The committee realized that accomplishing the goal is important but identified that sustainment is the most crucial aspect of the project. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> The documentation group will continue to monitor documentation, provide additional education for compliance and focus next on case-specific assessment/documentation.