Abstract
Currently, New York-Presbyterian Healthcare System (NYP) Post Anesthesia Care Unit (PACU) nurses document on a multi-system wide electronic health record (EHR). We utilize the PACU Admission and PACU Discharge/Transfer Note and five years ago designed the PACU Second Stage Admission and Discharge Notes. Reviews based on current practice revealed that all nurses chart differently and there is no standardized process for how nurses are documenting patient admissions and discharges.
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