TY - JOUR
T1 - Standardizing documentation for postoperative nausea andvomiting in the electronic health record
AU - DeBlieck, Conni
AU - LaFlamme, Anne Fishman
AU - Rivard, Mary Jane
AU - Monsen, Karen A.
PY - 2013/10
Y1 - 2013/10
N2 - Postoperative nausea and vomiting (PONV) remains a common postoperative complication that causes patient discomfort and increases health care costs. Clinicians use the American Society of PeriAnesthesia Nurses (ASPAN) guideline to help prevent and treat PONV. However, the lack of standardized terminology in the electronic health record (EHR) and the lack of clinical decision support tools make it difficult for clinicians to document guideline implementation and to determine the effects of nursing care on PONV. To address this, we created a concept map of the Perioperative Nursing Data Set (PNDS) that illustrates the relationship between elements of this standardized nursing terminology and the ASPAN guideline, using the Systematized Nomenclature of Medicine-Clinical Terms multidisciplinary terminology to fill any gaps. This mapping results in a standardized dataset specific to PONV for use in an EHR, which links nursing care to nursing diagnoses, interventions, and outcomes. The mapping and documentation in the EHR also allows standardized data collection for research, evaluation, and benchmarking, which makes perioperative nursing care of patients who are at risk for or experiencing PONV measureable and visible. Distributing this information to perioperative and perianesthesia nursing personnel, in addition to implementing risk assessment tools for PONV and clinical support alerts in electronic documentation systems, will help support implementation of the PONV clinical practice guideline in the EHR.
AB - Postoperative nausea and vomiting (PONV) remains a common postoperative complication that causes patient discomfort and increases health care costs. Clinicians use the American Society of PeriAnesthesia Nurses (ASPAN) guideline to help prevent and treat PONV. However, the lack of standardized terminology in the electronic health record (EHR) and the lack of clinical decision support tools make it difficult for clinicians to document guideline implementation and to determine the effects of nursing care on PONV. To address this, we created a concept map of the Perioperative Nursing Data Set (PNDS) that illustrates the relationship between elements of this standardized nursing terminology and the ASPAN guideline, using the Systematized Nomenclature of Medicine-Clinical Terms multidisciplinary terminology to fill any gaps. This mapping results in a standardized dataset specific to PONV for use in an EHR, which links nursing care to nursing diagnoses, interventions, and outcomes. The mapping and documentation in the EHR also allows standardized data collection for research, evaluation, and benchmarking, which makes perioperative nursing care of patients who are at risk for or experiencing PONV measureable and visible. Distributing this information to perioperative and perianesthesia nursing personnel, in addition to implementing risk assessment tools for PONV and clinical support alerts in electronic documentation systems, will help support implementation of the PONV clinical practice guideline in the EHR.
KW - EHR
KW - Electronic health record
KW - PNDS
KW - PONV
KW - Perioperative Nursing Data Set
KW - Postoperative nausea and vomiting
KW - Postoperative nursing
KW - Standardized nursing terminology
UR - http://www.scopus.com/inward/record.url?scp=84884520668&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=84884520668&partnerID=8YFLogxK
U2 - 10.1016/j.aorn.2012.12.021
DO - 10.1016/j.aorn.2012.12.021
M3 - Article
C2 - 24075333
AN - SCOPUS:84884520668
SN - 0001-2092
VL - 98
SP - 370
EP - 380
JO - AORN journal
JF - AORN journal
IS - 4
ER -