Less charting makes more sense with these forms
Old thinking: The more you document, the better off you are.
New thinking: If you spend less time with documentation, you have more time with the patient.
Same-day surgery managers seeking to use their staff more efficiently have fueled a trend toward "documentation by exception," a method of charting that requires nurses to make detailed notations only when the case doesn’t follow the expected outcomes.
Once nurses get over their inclination to "document, document, document!" they embrace the consistency, conciseness, and efficiency of documentation by exception, same-day surgery (SDS) managers say. Multipage forms can be condensed into a single perioperative flow sheet without sacrificing the quality of patient information, managers say.
"Nurses are ingrained that if it’s not documented, it’s not done," says Cheryl A. Sangermano, RN, BSN, CNOR, service line manager for perioperative services and the laser center at Grant Medical Center Eye and Ear Hospital in Columbus, OH. "We had to assure them that what we had in [the perioperative flowchart] was what needed to be documented. Frequently, they documented things that didn’t need to be documented.
"Once they started using the form, they absolutely loved it because it cuts down on the time they spend documenting."
No need to repeat questions
Grant Medical Center Eye and Ear Hospital once had four two-sided perioperative forms, which covered four areas: pre-op, holding room/intraoperative, postanesthesia care unit phase I recovery, and phase II recovery. To complete each form, different nurses asked many of the same questions of patients.
The Grant Hospital perioperative flow sheet now has a total of four pages one for each unit. They each contain problem statements that designate possible risks, outcome statements indicating what is expected to occur, and an area for nurses to note when the desired outcome was met. "We document the patient assessment, planning, nursing intervention, teaching, and patient outcomes," Sangermano says.
For example, a preoperative problem statement notes "high risk for anxiety related to surgical experience." The outcome statement says, "Patient will demonstrate no more than moderate anxiety."
"If that is not met, we asterisk it," Sangermano says. "In our preoperative notes, we explain why that was not met."
The intraoperative page includes such patient assessment items as oxygenation/circulation, cognition, and skin integrity. For example, an outcome statement says, "Patient’s fluid output will be monitored to facilitate volume replacement."
A separate, surgical procedure form accompanies this flowchart, listing such items as the time the patient enters and leaves the room, the personnel in the room, and sponge counts. It simply wasn’t possible to put everything on a one-page intraoperative form, Sangermano says.
Still, the condensed format of the flow sheet has advantages throughout the perioperative process, she says. The last page includes a section for medication that is used anywhere in the entire process.
"Whether someone is getting medications in the preoperative phase or the intraoperative phase, it’s listed there," says Sangermano. That section makes it easier for OR personnel to know what medication a patient has been given.
Check-boxes make charting easy
At St. Joseph’s Hospital of Atlanta, 20 pages of pre-op and post-op documentation have been reduced to a form that fits on the front and back of two pages. (See pre-op/post-op chart, inserted in this issue.) The tool includes a preadmission assessment, pre-op checklist, and perioperative and postanesthesia components. A separate procedure-specific care map and intraoperative form are used as well.
The St. Joseph’s forms rely heavily on boxes that nurses can check to indicate the patient assessment or that specific steps have been taken. For example, under discharge planning, nurses need only check a box showing they "reviewed post-op instruction sheet, copy given [to patient]."
In the extended recovery/observation area, which uses charting by exception, manager Brenda Wyatt, RN, CCRN, estimates that nurses can assess the patient and chart it in less than 10 minutes. Previously, nurses would have spent another 10 minutes just with the documentation, Wyatt says.
"Instead of writing everything out in longhand, you check that you’ve accomplished that particular requirement," she says.
While Wyatt does not have a specific estimate of cost-savings produced by charting by exception, she notes that the number of patients in the unit has increased while staffing has remained constant. "[Nurses] are spending time with the patients rather than at the nurses’ station charting," she says.
The condensed forms are also easier to read, says Penny Dykstra, RN, director of emergency, observation, and outpatient surgical services and co-director of continuum of care services at St. Joseph’s. "You can tell at a glance what [medications] they’ve had previously rather than hunting through the record," Dykstra says.
The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, is supportive of charting by exception, Sangermano says. In a Joint Commission survey at Grant Medical Center a year ago, "there were no problems with the documentation at all," Sangermano says. "They thought it was great."
(Editor’s note: See next month’s issue of Same-Day Surgery for a copy of Grant Medical Center’s perioperative flow sheet and a story on training nurses.)
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