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Simple pnds

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Simple pnds

  1. 1. SIMPLE PNDS<br />Education Design by: <br />Marisa Tapia MSN RN ACNS-BC<br />
  2. 2.
  3. 3. Hi Nancy, my name is Amelia<br /> I am the Informatics Nurse that will guide you through this tutorial<br />We’ll start with what does the PNDS stand for<br />
  4. 4. The PNDS stands for:<br />P<br />Perioperative <br />N<br />Nursing<br />D<br />Data <br />S<br />Set<br />
  5. 5. Okay… but what IS the PNDS?<br />
  6. 6. The PNDS reflects the perioperative clinical workflow which captures the perioperative nurse’s contributions to the patient outcomes via clinical documentation in the electronic health record<br />
  7. 7.
  8. 8. The PNDS language is a computer coded language built into the electronic record for Perioperative Nurses to capture the nurse’s documented data<br />
  9. 9.
  10. 10. In simple terms…<br />Whatever YOU enter into the electronic health record related to patient care, will be captured using the PNDS codes within the computerized program your facility uses. <br />
  11. 11. So let me get this right…..<br />
  12. 12. The PNDS codes capture the documentation of the care the nurse provide in the operating room to their patients in the electronic health record. <br />Click to save<br />
  13. 13. Am I on the right track? <br />
  14. 14. ITS IMPORTANCE<br /> 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 versus non-clinical variables or values such as turnover time.<br />
  15. 15. That is correct! <br />
  16. 16.
  17. 17. The PNDS includes computerized codes which will facilitate consistent electronic documentation, quality initiative identification, and clinical reporting in the perioperative setting.<br />
  18. 18. Let’s Review<br />
  19. 19. DEFINITION<br />The PNDS is a standardized vocabulary that describes perioperative nursing practice by providing formal definitions when the nurse is documenting the care being provided to the patient in surgery.<br />
  20. 20. Better said:<br />It is a standardized and controlled vocabulary that EVERY perioperative nurse uses to identify the work being done in the perioperative area when documenting or “charting” in the Electronic Healthcare Record (EHR).<br />
  21. 21. I GET IT!!!!! <br />
  22. 22. I GET IT!!! <br />A standardized single concept that<br />will capture every step, skill, and<br />care the perioperative nurse<br />provides to the patient undergoing<br />an operative or invasive<br />procedure when documenting <br />care in the Electronic<br />Health Record (EHR)<br />
  23. 23. YOU GOT IT!!!!<br />
  24. 24. But..what’s in it for me, more work? <br />
  25. 25. I already have too much to do and now this? <br />
  26. 26.
  27. 27. The PNDS will not make more work for you.<br />The PNDS will itemize what you do for the care you provide for each patient.<br />
  28. 28. THE PNDS WILL IDENTIFY THE TRUE VALUE OF THE WORK THAT NURSES PROVIDE WHEN CARING FOR THE PATIENT IN SURGERY.<br />
  29. 29. PNDS captures the essence of caring…<br />for the patient <br />
  30. 30. The PNDS uses the nursing process as the foundation for the documentation in the electronic health record <br />
  31. 31.
  32. 32. Finally…they will <br />understand what I do as<br />a nurse in the perioperative <br />setting!!!<br />
  33. 33. The true value of what the RN does! <br />The PNDS provides the documented value, cost-effectiveness, and contributions of professional nurses in the perioperative setting while gathering reliable perioperative data for future research related to perioperative nursing.<br />
  34. 34. From admission….<br />
  35. 35. …to documenting the care provided by the nurse in surgery…..<br />Click to save<br />
  36. 36. Positive Patient Outcome <br />PNDS captures all the data for this patient’s surgery and the care he received<br />GOAL MET<br />
  37. 37.
  38. 38. The PNDS is a computerized method to collect data to measure CLINICAL IMPACT as well as non- clinical variables/values such as turnover time<br />Let’s Recap:<br />
  39. 39.
  40. 40. Measuring turnover times of the room for the next case, although important at times, is not a measure of clinical nursing quality but a measure of efficiency (non-clinical processes) .<br />
  41. 41. The PNDS is…<br />
  42. 42. A method to document the value, cost-effectiveness, and the contributions ofprofessional nurses that are providingcare to the patient undergoing a surgical intervention…<br />
  43. 43. Isn’t that what we are supposed to be doing? <br />
  44. 44. My nursing <br />interventions matter!<br />
  45. 45. The work I do will now be captured, collected, validated and…..<br />
  46. 46. My work will be studied….and <br />
  47. 47. My work will provide the data for new evidence in practice<br />
  48. 48. I get that the PNDS provides<br />great value but….what can be gained from the PNDS? <br />
  49. 49. From this<br />To this<br />
  50. 50. Additionally,<br />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 establish data for best practices. <br />
  51. 51. What will all this stuff generate?<br />
  52. 52.
  53. 53. HOW is it done? <br />
  54. 54.
  55. 55. The information collected from the PNDS captures the nurse’s interventions which provide reliable perioperative data for nursing research. <br />
  56. 56. BUT…why use it?<br />Here are some reasons <br /><ul><li>Clarity, preciseness, and consistency in the documented care given by the perioperative nurse
  57. 57. Perioperative practice visibility by the data being generated reflecting the clinical work flow.
  58. 58. Records reliable and valid perioperative data
  59. 59. Allows for the comparison of the data being captured to compare effectiveness, efficiency
  60. 60. PNDS codes that are built into the electronic health record (EHR) allows you to document safe and effective care </li></li></ul><li>I am not quite sure I get it?<br />
  61. 61. Okay, this should help: <br />Based on what you document in the perioperative record the PNDS establishes and reports on: <br /><ul><li>Quality Measures
  62. 62. Patient-centered care
  63. 63. Evidence-based practice
  64. 64. Performance-driven outcomes </li></li></ul><li>NOW…Let’s put it all together so you can see the BIG picture of all the PNDS can do for YOU and the Patient<br />
  65. 65.
  66. 66.
  67. 67.
  68. 68.
  69. 69. Basic Elements of how it is identified in the Electronic Health Record<br />
  70. 70. Are You still with me? <br />
  71. 71. Following you so far….<br />
  72. 72. Let me give you an example<br />
  73. 73. Now, how would it look like <br />when I am documenting <br />the nursing interventions or the <br />work that I do ? <br />
  74. 74.
  75. 75. But where is the PNDS? <br />
  76. 76. The PNDS has built in codes <br />In the Electronic Healthcare<br />Record (EHR) that you don’t <br />See in practice but they are<br />there.<br />I will show you an example<br />
  77. 77. PNDS Codes are the data points that when you document will be captured and used for nursing quality outcomes<br />
  78. 78.
  79. 79. Now my nursing care will be<br />recognized in research studies, in evidence based practice and in nursing quality outcomes <br />
  80. 80. YOU GOT IT! <br />Let’s Celebrate<br />Your Success!<br />
  81. 81. You have earned <br />1.5 Contact Hours of Continuing Education<br />

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