The development of a postanesthesia record incorporating the nursing process

The professional practice of nursing is a comprehensive discipline involving assessment, planning, implementation, and evaluation in its approach to both daily practice and problem solving. An integral part of this process is the development of nursing diagnoses, setting of goals, and evaluation of progress towards meeting those goals. In order to further professional practice in the PACU, the PACU staff at St Francis Hospital in Greenville, SC, developed a new record that incorporates nursing diagnosis, goal setting, and evaluation along with the documentation of appropriate nursing interventions to meet stated goals. The staff believed that such a record would advance their professional practice, meet the ASPAN standards of nursing practice, and meet the Joint Commission for Accreditation of Healthcare Organizations requirements that documentation in the PACU show a nursing plan of care. The need for such a record was shown in the literature search and the record was developed, tested over a 30-day period, and implemented in September 1988. Staff response to the record has been very positive with nurses indicating that the record not only improved documentation, but also increased individual accountability for initiating nursing measures to meet stated goals.