Final simple pnds
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Final simple pnds






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    Final simple pnds Final simple pnds Presentation Transcript

      Education Design by:
      Marisa Tapia MSN RN ACNS-BC
    • We’ll start with what does the PNDS stand for ?
    • PNDS
    • WHY use it?
    • Here are some reasons
      • Clarity, preciseness, and consistency in the documented care given
      • Ensures visibility by the data being generated reflecting the clinical work flow.
      • Record keeping of perioperative data
      • Compare data being captured for effectiveness and efficiency
      • PNDS codes are built into the electronic health record (EHR) allowing you to document care that is safe
    • This is about the charting the nurse does…
    • The PNDS is…
    • A nursing language
      Not a computer program
      A method to document and collect perioperative nursing care data to evaluate nursing care to determine evidence based practice
      Let me show you…
    • Perioperative
      Clinical Workflow
      Perioperative Clinical Documentation
      Optimal Patient Outcome
    • The PNDS codes capture the documentation of the care the nurse provide in the operating room to their patients in the electronic health record.
      Click to save
    • Moving on to its importance…
    • Why relevant?
      The PNDS is an approved ANA (American Nurses Association) nursing language that provides a true perioperative standardized method of documentation to gather data in order to measure clinical impact versusnon-clinical variables or values such as turnover time (measurement of efficiency not nursing care).
    • This will produce…
      • Documented data
      • Provide solid evidence
      • Promote practice guidelines
      • Generate outcomes that will promote:
      • Evidence Based Practice
      • Benchmarking
    • Let’s Review
      The PNDS is a standardized vocabulary that describes perioperative nursing practice by providing formal definitions when the nurse is documenting the care provided to the patient in surgery via the electronic healthcare record (EHR)-The “charting”.
    • Will it create more work?
    • Nurses have so much to do already, adding one more thing could cause harm to the patient…
    • The PNDS will not make more work for you or harm the patient.
      The PNDS will itemize what you do for the care you provide for each patient.
    • PNDS:
      Identifies the true value of the work the nurse provides during the care of the patient in surgery
    • PNDS captures the essence of caring…
      for the patient
    • The PNDS uses the nursing process as the foundation for the documentation in the electronic health record
    • Correctly using this
      While providing this
      And documenting this…
      Will avoid this….
    • The RN in surgery: ROI
      The PNDS provides the documented value, cost-effectiveness, and the contributions of professional nurses in the perioperative setting while gathering reliable perioperative data for future research related to perioperative nursing care.
    • From admission….
    • …to documenting the care provided by the nurse in surgery…..
      Click to save
    • Turnover time is not a measurement of nursing care or nursing quality but rather a measurement of efficiency
    • …it documents thevalue ofprofessional nurses providingcareto the patient undergoing a surgical intervention…
    • Isn’t that what NURSES are supposed to be doing?
    • The work Nurses do in the operating room will now be captured, collected, validated and…..
    • …studied…but….
    • What can be gained from the PNDS?
    • Additionally,
      The care that is documented will be collected and is retrievable via the PNDS codes for data analysis and quality measures, such as SCIP and nurse sensitive patient outcomes (NDNQI) which will provide the evidence for best practices.
    • Researched and tested
    • Start with this
      To get to this
    • What will all this stuff generate?
    • But….
    • From this
      To this, for the perioperative specialty
    • Resulting in this
    • PNDS identifies and generates:
      • Quality Measures
      • Patient-centered care activity
      • Evidence-based practice guidelines
      • Performance-driven outcomes
    • Putting it all together…..
    • Let me give you an example
    • Surgical Counts:
      Every step will be documented from opening the sterile instruments, checking sterility, to performing the instrument count, separating sponges to performing a sponge count, to identifying items to be included in the surgical count.
    • The PNDS includes computerized codes which will facilitate consistent electronic documentation, quality initiative identification, and clinical reporting in the perioperative setting that will be built into the program your facility purchases.
    • PNDS has built in codes. These codes are the data points that when you document the care YOU provide, will be captured and used for nursing quality outcomes via the computer program your facility purchases.
    • Now the nursing care will be recognized in research studies, in evidence based practice and in nursing quality outcomes
    • So don’t practice like this…
      Or else…
    • This
      Will lead to this
    • Use this
      With this
      To gain this…
    • Positive Patient Outcome
      PNDS captures all the data for this patient’s surgery and the care he received
      GOAL MET
    • Resources
      Slide 5 HUH
      Slide 7 and 8 Cartoon
      Slide 11 Computer Screen Shot
      Slide 18 Frustrated nurse
      Slide 20 Focus on Quality
      Slide 28 Aha
      Slide 29 don’t forget
      slide 30 Einstein duh
      Slide 34 Boy reading
      Slide 56 judge and gavel
      Slide 57 computer on wheels (COW)
      Slide 10, 26, 27, 30-33, 35, 36, 38, 39, 40, 41- 50, 52, 53, 54, 55, 57 and 58 personal photographs and graphics M. Tapia and AORN .
      Slides 8, 56 (harm), photographs from Microsoft Office Online
      Slide 59 Choose the right tool