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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.
Oncology Nursing Forum
|May 25, 1999
Summary
A redesigned postoperative flowsheet for breast surgery patients improves nursing documentation efficiency and accuracy. This enhanced tool ensures consistent patient care in ambulatory settings, reducing staff time during busy office practices.
Area of Science:
- Nursing
- Ambulatory Care
- Surgical Oncology
Background:
- Existing postoperative flowsheets may not adequately capture essential nursing assessments and interventions for breast surgery patients in ambulatory care.
- Clinical experience and established standards of practice highlight the need for optimized documentation tools.
Purpose of the Study:
- To redesign an existing postoperative flowsheet for breast surgery patients.
- To ensure the flowsheet accurately reflects nursing assessments and interventions during each patient visit.
- To enhance documentation consistency and meet the evolving needs of ambulatory breast surgery care.
Main Methods:
- Review of Memorial Sloan-Kettering Cancer Center Standards of Practice for Ambulatory Care.
- Incorporation of clinical experience from nursing staff.
- Analysis of relevant published literature on surgical nursing documentation.
Main Results:
- A comprehensive postoperative flowsheet was successfully redesigned.
- The new flowsheet provides consistent documentation tailored to breast surgery patients in ambulatory settings.
- Implementation led to a decrease in staff documentation time.
Conclusions:
- The redesigned flowsheet accurately reflects nursing care provided to patients post-breast surgery.
- Consistent patient care can be maintained through the use of this comprehensive tool.
- Increased efficiency in nursing practice is achievable with the implemented flowsheet.