A Uniform Approach to Nursing Documentation:Ensuring Patient-Centered and Efficient Care in Preparing Surgical Patients

Background: Prior to surgery, patients are informed about the procedure. In addition, nurses gather information about specific patient factors such as anxiety, language barriers and domestic challenges. This preparation can occur months or weeks before surgery. <br/><br/>On the day of surgery, patients are received and prepared in the perioperative unit. Within a short timeframe, nurses must assess, and document patients’ specific needs and resources to facilitate high quality care and discharge. However, much of this information is already available in the patient’s electronic medical record, but due to different documentation practices within each surgical specialty no comprehensive overview of the patients’ specific needs was available. <br/><br/> <br/><br/>Aim: To develop and implement a uniform approach to documentation of the patients’ needs and resources before surgery. <br/><br/> <br/><br/>Methods: Clinical nursing directors organized a collaborative meeting involving 1–2 clinical nurse specialists from each department to develop a uniform documentation procedure. Once a consensus was reached on defining relevant information, necessary IT solutions were implemented to finalize the process and ensure consistent application across all specialties. <br/><br/> <br/><br/>Results: Nurses in the surgical specialties now document only essential information. <br/><br/>Nurses in the perioperative unit can now access a comprehensive overview of relevant information in the patients’ electronic medical records. This allows for better planning of care for patients with special needs and ensures that patients feel seen, acknowledged, and welcomed. <br/><br/> <br/><br/>Conclusion: Bringing all relevant stakeholders together for a full-day collaboration enabled the creation of an effective, uniform documentation tool, benefiting both patients and nursing efficiency.