Revised Draft 9/19/10

1. SIMPLE PNDS Education Design by: Marisa Tapia MSN RN ACNS-BC

3. We’ll start with what does the PNDS stand for

4. PNDS P Perioperative N Nursing D Data S Set

5. WhatIS the PNDS?

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.

8. The PNDS language is a computer coded language built into the electronic record for Perioperative Nurses to capture the nurse’s documented data

10. In simple terms… 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.

11. This is about the charting the nurse does…

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. Click to save

13. Moving on to its importance…

14. 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).

15. The PNDS includes computerized codes which will facilitate consistent electronic documentation, quality initiative identification, and clinical reporting in the perioperative setting.

17. Provide solid evidence

18. Promote practice guidelines

19. Generate outcomes that will promote:

20. Evidence Based Practice

22. DEFINITION 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.

23. Better said: 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).

24. Simplified!!! A standardized single concept that will capture every step, skill, and care the perioperative nurse provides to the patient undergoing an operative or invasive procedure when documenting care in the Electronic Health Record (EHR)

25. Will it create more work?

26. Nurses have so much to do already… adding one more thing could cause harm…

27. The PNDS will not make more work for you. The PNDS will itemize what you do for the care you provide for each patient.

29. PNDS: Identified true value of the work the nurse provides during the care of the patient in surgery

30. PNDS captures the essence of caring… for the patient

31. The PNDS uses the nursing process as the foundation for the documentation in the electronic health record

32. Correctly using this While providing this And documenting this… Will avoid this….

34. The RN in surgery: ROI 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.

35. From admission….

36. …to documenting the care provided by the nurse in surgery….. Click to save

37. Positive Patient Outcome PNDS captures all the data for this patient’s surgery and the care he received GOAL MET

39. The PNDS is a computerized method to collect data to measure CLINICAL IMPACT as well as non- clinical variables/values such as turnover time Let’s Recap:

41. 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) .

42. The PNDS is…

43. …it’s a method to document the value, cost-effectiveness, and the contributions ofprofessional nurses that are providingcare to the patient undergoing a surgical intervention…

44. Isn’t that what NURSES are supposed to be doing?

45. The work Nurses do in the operating room will now be captured, collected, validated and…..

46. studied…

47. Researched and tested

48. What can be gained from the PNDS?

49. From this To this

50. 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 establish data for best practices.

51. What will all this stuff generate?

53. HOW is it done?

54. From this To this, for the perioperative specialty

56. The information collected from the PNDS captures the nurse’s interventions which provide reliable perioperative data for nursing research.

58. Ensures visibility by the data being generated reflecting the clinical work flow.

59. Record keeping of perioperative data

60. Compare data being captured for effectiveness and efficiency

62. Patient-centered care activity

63. Evidence-based practice guidelines

67. Basic Elements of how it is identified in the Electronic Health Record

68. Let me give you an example

69. Surgical Counts: Every step will be documented from opening the sterile instruments, checking sterility, to performing the instrument count, separating sponges to perform a sponge count, to identifying items to be included in the surgical count.

72. PNDS has built in codes. These codes are the data points that when you document will be captured and used for nursing quality outcomes

73. Now the nursing care will be recognized in research studies, in evidence based practice and in nursing quality outcomes

74. You have earned 1.5 Contact Hours of Continuing Nursing Education