An Evidence-based Preoperative Evaluation Documentation Template Improves Perioperative Communication

Area of Science:

• Healthcare Quality Improvement
• Medical Informatics
• Surgical Patient Care

Background:

• Surgical procedures have increased, with a trend towards ambulatory care settings.
• Perioperative complications and mortality represent significant healthcare burdens.
• Deficiencies in preoperative assessment and documentation lead to communication failures and adverse patient outcomes.

Purpose of the Study:

• To design and implement an improved preoperative evaluation documentation template.
• To enhance communication within the perioperative pathway.
• To improve the overall user experience with preoperative documentation.

Main Methods:

• A revamped, evidence-based documentation template was implemented in electronic medical records across multiple clinics.
• A pre- and postintervention study design was employed.
• Template utilization rates and clinician satisfaction were assessed.

Main Results:

• The utilization rate of the preoperative template increased significantly from 51.2% to 66.5%.
• Clinician satisfaction with the documentation template saw a substantial rise, from 30.6% to 80.0%.
• Both increases were statistically significant (p < 0.001).

Conclusions:

• A user-friendly, evidence-based documentation template can standardize preoperative evaluation.
• Implementation of such templates can effectively reduce the documentation burden on clinicians.
• Improved documentation facilitates better communication and potentially better patient outcomes.