Standardizing Electronic Documentation Using a Perioperative Nursing Language


Our places of work and homes are abuzz with new terms: toxic assets, monetary policy and stimulus packages. While the current state of the economy is to many a relatively new development: cost containment, productivity and revenue struggles are not new to healthcare. Consider the dizzying predicament for healthcare professionals when economic issues are mixed with industry issues such as safety, quality, evidence-based care and pricing transparency. Adding regulations offering incentives for the “meaningful use” of electronic health records (EHR) and the clinical care environment transitions into a tense, high-pressure conflict between actual care, documentation and data collections.

In the midst of this conflict and pressure is the professional nurse. No doubt, nurses affect clinical care and patient outcomes. A report studying the effects of nurse-to-patient ratio validated a strong correlation with reducing patient morbidity and mortality.1

However, healthcare organizations, especially perioperative areas, have difficulty with data collection, integrity and retrieval that provides the basis for operational and clinical decisions. Poor or inconsistent data restrains the allocation of appropriate resources or tools to develop a scientific foundation for an evidenced-based nursing practice model.

Increasingly, healthcare and the perioperative environment are going digital. With this transformation, there is a need to provide rigorous standards that promote safe patient-centered care. A market survey of over 200 perioperative units in healthcare facilities and ambulatory surgery centers (ASCs) revealed many wanted, or had some version of, the Perioperative Nursing Data Set (PNDS) in their documentation, but did not know how to incorporate it into their plan of care. Additionally, the respondents were unsure if their documentation met standards or regulatory requirements due to the complex regulatory environment and the difficulty of maintaining the frequent updates.2

Clearly, healthcare organizations need to identify the critical factors to be employed when developing an information infrastructure and the tools to quantify efficient, cost-effective quality care. By applying a standardized perioperative language, the clinical environment has a mechanism to aggregate consistent data representing patient-centered care. The American Medical Informatics Association (AMIA) also offers additional guidance for selection and implementation of an information system to promote a national infrastructure for healthcare:

  • Establish a local, regional and national health information exchange (HIE) to ensure that health information is available whenever and wherever needed
  • Create standards, policies and practices that foster security, confidentiality, transparency and public trust
  • Identify health terminologies and classifications allowing health data to be uniform and consistent across information systems
  • Link information related to individuals in order to ensure the validity and integrity of health data for care and research
  • Develop decision making and other knowledge management tools in order to permit delivery of individualized, evidence-based care
  • Develop appropriate and secure linkages between EHRs and the public health surveillance systems.3

The PNDS is foundational to this effort as it meets an essential point of the information infrastructure criteria by providing clear, consistent and precise terminology, and definitions for clinical problems (nursing diagnoses), nursing interventions and patient outcomes, and reflect perioperative nursing practices.4 The PNDS is not a standard of care, but a structured vocabulary allowing the aggregation of clinical information across the perioperative continuum of care. In a standardized perioperative framework, the PNDS is associated with practice standards, accreditation criteria and regulatory requirements to facilitate efficient and safe patient care, while staying current with changes in healthcare. Throughout the healthcare system, initiatives to promote patient safety, improve outcomes and report consistently on quality metrics are gaining considerable momentum. Congress has directed the Centers for Medicare and Medicaid Services (CMS) to put into place a reporting system for ASCs to track quality by the end of this year, with financial penalties for those failing to submit the required data.5

Responding to this heightened emphasis on quality reporting will not be easy. Compliance with the Joint Commission or other accreditation standards is another concern for ASCs. Automating documentation in the clinical setting can greatly improve the ability to meet these goals. Information systems not only satisfy regulatory demands, it also reduces inefficient manual processes.

Healthcare organizations do not want to re-invest in a new surgical information system but want collected data to be used more efficiently for benchmarking and quality initiatives. A standardized data framework that overlays the existing user information documentation system and standardizes perioperative documentation and nursing workflow will help guide decision making for patient-centered care. Such a framework enables hospital decision makers and nurses to:

Guide safer care by integrating:

  • The Association of periOperative Registered Nurses’ (AORN) Perioperative Standards and Recommended Practices
  • Regulatory and mandatory reporting requirements
  • Accreditation standards
  • PNDS
  • Consistent, standardized communication.

Guide effective care by:

  • Enabling evidenced-based clinical decisions
  • Providing information to develop protocols
  • Integrating current regulatory requirements, accreditation criteria and national standards
  • Promoting nurse-sensitive interventions and plan of care.

Drive efficient care by:

  • Returning nurses from the conference room to the operating room
  • Reducing nurse documentation time
  • Facilitating perioperative staff training by
  • Training new orientees
  • Orientating temporary staff.

The framework should complement rather than replace any information technology (IT) vendor system, focusing on standardizing the perioperative content of the EHR, nursing documentation and functionality with surgical information systems. There are four general categories of technology that should be considered when purchasing any new IT application:

  • Presentation – what is seen on the screen
  • Workflow – how information is proceeded and sequenced
  • Reference files – tables and files of predetermined values, such as allergy types or patient positions
  • Data – where patient-level information is stored

With this framework, healthcare organizations can standardize the perioperative content for workflows and reference files.

Workflows should be standardized across both the perioperative continuum (pre-admit to post operative recovery) and throughout the nursing cycle (assessment, nursing diagnosis, desired outcome, implementation, evaluation and actual outcome)

Reference files should be created by the organization implementing the system. The framework provides a comprehensive and detailed list of standardized reference files scalable to any organization.

So how does all of this represent patient-centered care?

  1. It does not require more documentation; it is transparent to the user
  2. It integrates national standards, recommended practices and regulatory requirements across all phases of perioperative care
  3. It employs PNDS as the universal perioperative language with associated data elements reflecting nursing interventions
  4. It reflects nursing workflow in the entire plan of care, assessment, implementation, evaluation and patient outcomes
  5. Enables data to be used for benchmarking, both internally and externally
  6. It supports national mandatory reporting measures (e.g., Surgical Care Improvement Project measures) by utilizing continued documentation of the assessment findings throughout all phases of perioperative care
  7. It supports the submission of required CMS quality data.



  1. J. Needleman, PI Buerhaus. Nurse Staffing Levels and Quality of Care in Healthcare Organizations. The New Eng J of Med May 30, 2002, No. 22, Vol 346:1715-1722
  2. CSC market survey conducted on behalf of AORN from 8-1-2008 thru 9-30-2008.
  3. D. Detmer. AMIA recommendations for achieving a national infrastructure for HIT and  informatics to President-Elect Obama. January 7, 2009. Accessed April 3, 2009.
  4. C. Peterson, ed. Perioperative Nursing Data Set Revised 2nd ed. Denver: CO: AORN, INC; 2007:9-15.
  5. Centers for Medicare & Medicaid Services (CMS). 2008Deficit Reduction Act (DRA) 2005 (c). Accessed April 3, 2009.

Sharon Giarrizzo-Wilson, RN, BSN/MS, CNOR, is a perioperative nurse specialist, in Clinical Informatics for AORN. Julie Hammersley, RN, is a senior manager in the Perioperative practice at CSC. Louise Kenney, RN, is a senior manager in the Perioperative practice at CSC. Barbara Ripollone, RN, is a partner and the solution leader for the Perioperative/Supply Chain practice at CSC.


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