Development of an outpatient perioperative care record

Since the 1970s outpatient surgery has become increasingly popular as a mechanism for reducing hospitalizations and allowing patients to recuperate in their own homes. Advanced nursing care, improved surgical procedures, and modern pharmaceuticals and anesthetic techniques increase the rate and quality of patient recovery and allow the patient to enter the hospital, undergo surgery, and be discharged in the same day. It is now estimated that more than 40% of all surgeries are being performed in the outpatient setting. The rapid turn-around time for outpatient surgeries creates new challenges for nurses as well as patients and their families. Documentation of surgical procedures and nursing care is essential for communicating with other providers and for establishing a legal document that can be used to evaluate the quality of services delivered. Yet the time available for record keeping is greatly reduced. New charting procedures are needed to decrease redundancy and enhance the structural efficiency of perioperative records. This article describes a method of streamlining perioperative outpatient surgery records. The use of nursing diagnoses is incorporated into a documentation system that uses checklists, flowsheets, and charting by exception.