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A flowsheet for documenting independent nursing visits after breast surgery
R E Gross1, A Walsh, J H Davis
1Breast Service Ambulatory Care Nursing Department, Evelyn H. Lauder Breast Center, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
Purpose/Objectives:
To redesign a postoperative flowsheet already used in clinical practice with patients who have undergone breast surgery to reflect documentation of assessments and interventions noted on each nursing visit.
Data Sources:
Memorial Sloan-Kettering Cancer Center Standards of Practice for Ambulatory Care, clinical experience, and published articles.
Data Synthesis:
A comprehensive flowsheet was redesigned to provide consistency in documentation and reflect current needs of patients who have undergone breast surgery who are in ambulatory care.
Conclusions:
Implementation of the new flowsheet has decreased staff documentation time during busy office practices and accurately reflects the nursing care provided to patients after breast surgery.
Implications For Nursing Practice:
Consistency in patient care can be maintained and efficiency can be increased with use of a comprehensive flowsheet.