A standards of care plan in the postanesthesia care unit

Every patient is entitled to consistent, high-quality, individualized care. The PACU staff and former director of staff education at Southwestern Vermont Medical Center developed a documentation tool to achieve this end. The primary focus of the tool is on standards of care with an emphasis on outcome standards. Every patient received and cared for in the PACU is evaluated in terms of these outcome standards. If for any reason an outcome standard is not achieved, appropriate action is taken. The four-page bifold tool incorporates the nursing process. Potential nursing diagnostic problems are described and assessment and intervention data are integrated accordingly. The plan is further individualized vis à vis nursing progress notes. The tool has been in use for well over 1 year, and quality assurance studies demonstrate that outcome standards achieved and not achieved are consistently documented. The PACU staff believe this tool has enhanced professional practice and improved use of the nursing process and standards of care.