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…
Provide solid evidence
Promote practice guidelines
Generate outcomes that will promote:
Evidence Based Practice
DEFINITION 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.
…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…..
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?
From this To this, for the perioperative specialty
Resulting in this
PNDS identifies and generates:
Patient-centered care activity
Evidence-based practice guidelines
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 http://krapps.com/2009/07/13/mischief-lure-drawing-iphone-app/ Slide 7 and 8 Cartoon http://www.nataliedee.com/archives/2009/Jun/ Slide 11 Computer Screen Shot http://www.downloadpipe.com/Windows/network-internet-terminal-telnet-clients/review-ZOC-Terminal-SSH-Telnet-Serial-73906.html Slide 18 Frustrated nurse http://www.shutterstock.com/pic-13153471/stock-photo-young-nurse-stressed-out-and-upset-at-work.html Slide 20 Focus on Quality http://www.fotolia.com/id/1040805 Slide 28 Aha http://femibeckley.blogspot.com/ Slide 29 don’t forget http://www.mikemccready.ca/blog/2009/02/my-new-favorite-blogging-toy-scribefire/ slide 30 Einstein duh http://loanworkout.org/2009/05/can-all-homeowners-get-free-foreclosure-help/ Slide 34 Boy reading http://www.cclibraries.com/index.php/centennial-celebration Slide 56 judge and gavel http://www.memphisinjurylawyerblog.com/divorce/ Slide 57 computer on wheels (COW) http://www.interiormall.com/cat/ndisplaycoll.asp?c1=Furniture&book=1738 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 http://office.microsoft.com/en-us/clipart/default.aspx Slide 59 Choose the right tool http://webtools4u2use.wikispaces.com/Finding+the+Right+Tool