Patient-focused perioperative documentation: an outcome management approach

Perioperative nursing care and subsequent documentation is a key component in the continuum of care for the pediatric burn and reconstructive patient. A system was developed to streamline and improve the method of documentation, avoid inconsistencies, and provide an ongoing means of performance improvement monitoring. Narrative documentation is limited to charting by exception. The preoperative and intraoperative forms were developed in conjunction with the Perioperative Standards of Nursing Practice and integrated with policies and procedures already established. These guidelines are intended to incorporate the physician orders and recommended practices of professional organizations.