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Building the Best Practice Nursing Documentation in OR Manager
June 22, 2021

In June we discussed best practices around intraoperative documentation. Many times, documentation screens are built and fields are added when needed but are not often reviewed to make sure the documentation screens follow best practices. Several hospitals that I have visited over the last few years have had many documentation screens in the case record—one was even over 25 screens. A best practice case record should have between 8 and 10 screens maximum.

Picis recommends that the screens are reviewed every 18 to 24 months to ensure that they are efficient for the end user to document the case record or schedule the patient. One of the things to look for is free text fields. The goal is to have as few free text fields as possible. Reporting on a free text field is almost impossible since the user has the freedom to document the information in different ways. If users are documenting the same information in a free text field over and over again, it is wise to build a field for the information with a table associated as a drop-down box for the user to choose the answer. Typically, any notes needed in the case record can be entered in a word processing field. That field can be added to each screen and all notes are documented in one place on the case record that is printed or sent electronically to the EMR. Another nice feature on the word processing field is the ‘Audit’ button that allows the user to document username, date and time with one-click on the comments that were made by the user.

A question to ask the users is where is the ‘Actual Procedure’ documented. If a field has been created in the case record to document the ‘Actual Procedure’ it needs to be eliminated and the users need to have some education on how to enter that information on the header in the ellipsis box. Making sure the users document the procedures in the correct area of the case record in essential in ensuring the average case times are correct when scheduling that procedure, the next time.

When evaluating the case record make sure you are taking advantage of the AORN PNDS (Perioperative Nursing Data Set). Picis provides the interventions and outcomes straight from AORN to document the nursing care plan. When the user right clicks on the PNDS field the system will show the intervention that the clinician has selected and what outcome it is associated with. There is also a field in the PNDS details where the hospital policies and procedures can be entered for the clinician to review.

One more item to review is time fields. First, you want to ensure that you are using the standard time fields in the system. This will help to ensure the Standard Reports are pulling the correct information. Second, review the time fields the users are documenting and make sure they can document it correctly and they are not guesstimating or making up times. For example, ‘Setup Time’ is a field I often see in the case record. The setup time is a difficult time for the users to document correctly. Many times, the circulator is not in the room when set up has started and they must rely on others for the actual time. Usually that time is a guesstimate and not accurate. This is not a good field to rely on for statistical data.

Reviewing all documentation in all modules of Picis is a good practice and can make documentation efficient and allow the clinician time with the patient and not the computer.

About the Author

Theresa Sullivan, Director, Sales Support

Theresa has worked for Picis for 15 years and is currently the Director of Sales Support. With Picis, Theresa has implemented the Picis solutions across a variety of commercial and VA facilities, functioned as a Clinical Consultant in Sales, managed the Picis Reference Program and supported customers as a Senior Strategic Consultant in professional services. Before coming to Picis, Theresa was the Clinical System Administrator at a large medical center in Houston, Texas.


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