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Related Experiment Videos

Adapting charting by exception to the perianesthesia setting.

L A Anderson1, C A Schramm

  • 1John Dempsey Hospital, University of Connecticut Health Center, Farmington 06030, USA. Landerson@up.uchc.edu

Journal of Perianesthesia Nursing : Official Journal of the American Society of Perianesthesia Nurses
|May 29, 2000
PubMed
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This study adapted charting-by-exception principles to create a unified ambulatory surgery nursing record, aiming to streamline documentation and improve patient care quality from admission to discharge.

Area of Science:

  • Nursing Informatics
  • Ambulatory Care
  • Healthcare Documentation

Background:

  • Healthcare settings face pressure to reduce patient length of stay and increase patient-centered care.
  • The shift towards ambulatory patient care necessitates efficient and effective nursing documentation.

Purpose of the Study:

  • To adapt charting-by-exception principles for ambulatory surgery nursing.
  • To develop a single nursing record for the entire ambulatory surgery patient journey (admission to discharge).
  • To condense documentation, reduce time spent documenting, and minimize quality variance.

Main Methods:

  • Application of charting-by-exception principles.
  • Development of a unified ambulatory surgery nursing record.
  • Focus on measuring patient outcomes and promoting 'street readiness'.

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Main Results:

  • A condensed and standardized nursing record was created.
  • Potential for decreased documentation time and improved documentation quality.
  • The record facilitates outcome measurement for ambulatory surgery patients.

Conclusions:

  • Adapting charting-by-exception can optimize nursing documentation in ambulatory surgery.
  • A unified record supports efficient patient care and outcome assessment.
  • The developed record promotes patient readiness for discharge and continuity of care.