The perioperative nursing data set—a new language for documenting care

AORN Journal,  July, 2005  

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The article "The Perioperative Nursing Data Set: A new language for documenting care" is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, education program professional, Center for Perioperative Education.

Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is July 31, 2008.

Complete the examination answer sheet and learner evaluation found on pages 61-62 and mail with appropriate fee to

AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711

or fax the information with a credit card number to (303) 750-3212.

You also may access this Home Study via AORN Online at http://www.aorn.org/journal/homestudy/default.htm.

BEHAVIORAL OBJECTIVES

After reading and studying the article on the Perioperative Nursing Data Set (PNDS), nurses will be able to

1. explain what the PNDS is,

2. describe how the PNDS can be used to ensure quality patient care,

3. identify the four classifications of quality measures, and

4. discuss the results of trend data analysis of one data point that was monitored in the feasibility testing described in this article.

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

A minimum score of 70% on the multiple-choice examination is necessary to earn 1.9 contact hours for this independent study.

Purpose/Goal: To educate perioperative nurses about using the Perioperative Nursing Data Set for documenting care.

Home Study Program

The Perioperative Nursing Data Set--a new language for documenting care.

Susan V.M. Kleinbeck, RN; Annette Dopp, RN

Adoption and use of an electronic health record (EHR) holds the promise of improving the quality of patient care, promoting patient safety, controlling health care costs, and enhancing clinical research. Transforming health care documentation to an electronic format is dependent on the availability of standardized terminologies that reflect the reality of the clinical setting. Communication between health care providers will become more clear, precise, and concise when the terms used are standardized, discipline specific, codified, and linked in a relational database. (1)

Nurses should and do use a standardized vocabulary in the same way other health care providers do, that is, to describe clinical problems, interventions, and patient outcomes. Use of a standardized language decreases patients' risk for injury by eliminating inconsistency of language or meaning. Drawing comparisons, attempting to benchmark one facility to another, and managing information in an electronic format is impossible when definitions of data points are unclear. The Perioperative Nursing Data Set (PNDS) is an interface terminology designed to facilitate communication about surgical and invasive-procedure nursing care from pre-admission through recovery at home. The purpose of this paper is to inform health information managers of the value of the codified PNDS and to illustrate its use.

PROBLEM STATEMENT

Financial and facility outcomes are monitored and trended on a regular basis in the perioperative environment. Less attention has been paid to clinical or operational outcomes primarily because of the absence of a standardized clinical language specific to the perioperative setting. The absence of coded, accurate patient data is not new. As early as 1863 a similar complaint was published by Florence Nightingale,

   In attempting to arrive at the truth, I
   have applied everywhere for information,
   but in scarcely an instance have I
   been able to obtain hospital records fit
   for any purposes of comparison. (2)

The PNDS language permits consistent and accurate documentation of patient safety, infection control interventions, and achievement of regulatory-agency requirements, as well as facilitates charting compliance and management of supply costs.

BACKGROUND

The Association of periOperative Registered Nurses (AORN) is a professional organization of 40,000 nurses committed to providing cost-effective, quality perioperative nursing care. Since 1993, members of AORN have been actively working to describe, define, and establish a database that represents the practice of perioperative nursing. The first step in this process was the development of the PNDS. In 1999, the PNDS was recognized as a clinically relevant and empirically validated standardized nursing language by the American Nurses Association, and in 2004, it was incorporated in the Unified Medical Language System at the National Library of Medicine. The language is HL7 registered, and concepts are mapped in SNOMED Clinical Terms, the United States Government infrastructure for computerized health and medical information. Eleven vendors of EHR software currently hold a PNDS license, allowing them to incorporate the language into their software.