The change experience: how we updated our perioperative nursing documentation

Area of Science:

• Nursing Documentation
• Perioperative Care
• Healthcare Quality Improvement

Background:

• Effective perioperative nursing documentation is crucial for patient safety and continuity of care.
• Standardized forms can enhance communication and reduce errors in the operating theatre.
• Reviewing and updating documentation processes is essential for maintaining best practices.

Purpose of the Study:

• To describe the systematic review and modification process for perioperative nursing documentation forms.
• To promote transparency in the development of updated nursing documentation tools.
• To encourage perioperative practitioners to evaluate and enhance documentation within their departments.

Main Methods:

• A comprehensive review of existing perioperative nursing documentation forms was conducted.
• Modifications were implemented based on identified areas for improvement and best practice guidelines.
• The process focused on clarity, efficiency, and completeness of recorded patient information.

Main Results:

• The review identified specific areas within the documentation forms requiring updates.
• A revised set of perioperative nursing documentation forms was developed.
• The process aimed to create a more user-friendly and effective documentation system.

Conclusions:

• The described review and modification process provides a transparent model for updating perioperative nursing documentation.
• Encouraging interdepartmental sharing of such processes can lead to widespread improvements in nursing documentation standards.
• Standardized and updated documentation forms contribute to enhanced patient care and safety in surgical settings.