Education and Training for Documentation of Anesthesia Preoperative Interviews to Improve Capture and Reduce Lost...

To formulate and implement a sustainable, structured educational approach for preanesthesia testing (PAT) nurses focused on best practices in conducting preanesthesia interviews and capturing associated charges.

This quality improvement project utilized a pre- and post-implmentation design as well as a retrospective chart review.

All nine PAT nurses assigned to the PAT clinic at a community hospital in the Southeastern United States were asked to complete online educational modules on preoperative anesthesia interview (PAI) concepts and on proper PAI documentation, charge capture, and the use of a documentation checklist. Pre-/postimplementation data were collected on registered nurse (RN) knowledge and confidence, PAI documentation and subsequent charge capture accuracy, and the financial impact of improper charge capture.

RN knowledge increased significantly postimplementation from 82.6% to 97.2%, yet RN confidence did not show statistically significant improvement. Four months postimplementation, nursing documentation showed a 3.8% improvement in accuracy from 92.76% preimplementation to 96.25% postimplementation. This change in documentation accuracy led to improved charge capture, which yielded a significant decline (63.6%) in mean monthly monetary discrepancies from $2,962.50 preimplementation to $1,078.13 postimplementation.

This quality improvement project demonstrates a significant impact of structured education and a standardized checklist on PAT nursing practices. These interventions increased RN knowledge of preoperative interview components, improved documentation practices, and increased charge capture accuracy, which was associated with a marked reduction in charge discrepancies. This underscores the importance of thorough documentation practices, the correlation between documentation and institutional revenue, and the fiduciary responsibility of PAT nurses.