Standardized Nursing Documentation
Our Standardized Nursing Documentation provides recommended health record fields to enhance sharing and comparing of data and ensures that evidence-based care is documented throughout all phases (preadmission testing/preoperative, intraoperative, and postoperative). The health record fields are mapped to the Perioperative Nursing Data Set (PNDS) to link documentation to evidence-based nursing interventions.
4 Important Questions (& Answers) to Ask About Your Standardized Documentation
Do you constantly find inconsistencies in your documentation?
We perform the research to ensure nursing documentation content demonstrates evidence-based care reducing staff resources dedicated to perform this work.
How confident are you in your data?
We’ll help you avoid discrepancies in your data metrics. Improve consistency from patient to patient, which will significantly improve your overall patient care. Confidence in your data will also lead to more reliable data capture for research and better patient care plans.
Is your current documentation periop-specific?
Our documentation is created specifically for the perioperative environment. Created by the leaders in the perioperative industry. It’s tailored to the perioperative setting and ensures that all phases of care in the perioperative setting (preoperative, intraoperative, and postoperative) are properly documented.
Is your data capture process reliable?
We can help provided reliable data capture by using the documentation provided by AORN to ensure that each step of perioperative care is properly documented, allowing patient outcomes and operational data to be compared, evaluated, and used to enhance patient care and operational efficiency.
Most importantly, Standardized Nursing Documentation provides the perioperative nurse the ability to document the detailed nursing care that was provided.
The Perioperative Nursing Data Set (PNDS)
The Perioperative Nursing Data Set (PNDS) is only nursing language that provides standardized terminology to support perioperative nursing practice. It also includes positive outcome statements that reflect patient responses to perioperative nursing care. The PNDS represents the evidence-based practice that perioperative nurses provide and highlights the nurses’ contribution to patient outcomes.
5 Important Questions (& Answers) to Ask About Nursing Data Sets
Do your patient care plans represent perioperative nursing care?
We provide care plans that promote patient-focused outcomes and nursing interventions specific to the perioperative environment that easily identifies outcomes that should be addressed beyond the perioperative period.
We can help you improve standardization by reinforcing your nursing care plans you routinely use in clinical applications. Standardize vocabularies will provide uniformity to the language used by clinician's to develop care plans and accurately document nursing care.
Could your patient care be improved?
We can help enhance your patient care by improving data analysis to allow your department to measure, monitor, and evaluate the quality and effectiveness of care every time.
How structured is your clinical research process?
We can help improve your research process by providing a framework to help clinicians and researchers identify which interventions contribute to specific outcomes.
Do you have an effective process to measure your staff’s contributions?
We can help measures the value of your nurses’ contributions by providing the information you need to provide policy makers, legislators, and insurers on the crucial nursing data required to understand how nurses contribute to cost-effective quality care.
How confident are you in the data you provide to government regulators?
We’ll also help meet regulatory and accreditation standards. We address all accreditation organizations.
Contact Us Today
AORN Syntegrity can help make you, your team, and your entire facility more efficient and more profitable. Contact an AORN Syntegrity Sales Consultant at Syntegrity@aorn.org or 800-755-2676 x223.