Guideline for Patient Information Management: Key Takeaways for Periop Nurses

Highly reliable data collection processes are necessary not only to chronicle a patient’s response to nursing interventions and clinical improvement of the patient, but also to demonstrate the healthcare organization’s progress in and dedication to improving outcomes.

This guideline outlines areas for a comprehensive perioperative documentation plan that includes nursing workflow, data capture, required components, and electronic platforms. It is not inclusive of all required HCR documentation elements, nor should it be seen as the only guideline to be followed when developing or revising clinical perioperative documentation policies and procedures.

Perioperative Record Design

Convene an interdisciplinary team that includes perioperative RNs and nurse informaticists to design, edit, and customize all perioperative patient information management systems and tools that will be used in the organization.

Perioperative RNs can provide insights into their workflow and how documentation, especially with new electronic systems and tools, corresponds with delivery of perioperative nursing care. For example, perioperative RNs understand the consequences of documentation burden related to duplicative data entry.^3.1

Documentation and Nursing Workflow

Synchronizing documentation with the workflow of the perioperative team must include procedures for:

• having knowledgeable individuals monitor key safety metrics and available to educate, test, and provide continuous support to clinicians
• designing the workplace environment for safe use
• reporting workflow disruptions and identifying potential solutions
• ordering and administering medications, diagnostic tests, and procedures
• reporting patient safety hazards, providing steps to address them, and overriding CDS interventions, when necessary
• requiring accurate patient identification that is clearly displayed on screens and printouts at each step in clinical workflow
• tracking the status of order administration ^4.1

Informed Consent Documentation

Policies and procedures must detail the organization’s informed consent process, in accordance with applicable state and federal regulations, including:

• who may obtain the patient’s informed consent
• the operative and other invasive procedures for which informed consent is required
• the circumstances under which an operative or other invasive procedure is deemed an emergency and may be undertaken without informed consent
• the circumstances in which a patient’s representative, rather than the patient, may give informed consent for an operative or other invasive procedure
• the process used to obtain informed consent, including how informed consent is to be documented in the HCR
• methods to verify that informed consent is complete and documented in the HCR before the procedure
• if consent is obtained outside of the facility, how the properly completed informed consent form is incorporated into the patient’s HCR before the operative or other invasive procedure ^5.2

Orders Documentation

All patient care orders given in the perioperative patient care setting (e.g., verbal, standing order sets, items found in preference cards that require an order (e.g., medications) must be documented in the perioperative patient HCR62,70 and must be dated, timed, and authenticated by the ordering healthcare practitioner with prescriptive authority, in accordance with the individual’s scope of practice; the health care organization’s policies and procedures and medical personnel bylaws; and local, state, and federal laws. ^6.1

About eGuidelines Plus

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About AORN Syntegrity

AORN Syntegrity is an evidence-based EHR optimization tool designed to improve perioperative documentation processes, streamline workflows, and ensure patient safety. It provides access to over 2,900 perioperative procedures referenced to CPT®, ICD-10-PCS, and SNOMED-CT®, maintained by perioperative clinicians for accuracy. Additionally, it offers standardized nursing documentation to enhance efficiency through the perioperative nursing data set (PNDS), specialty content for tailored procedures, and hyperlinks to eGuidelines Plus for quick clinical support.

Patient Information Management Guideline References

^3.1 Edemekong  PF, Annamaraju  P, Haydel  MJ. Health Insurance Portability and Accountability Act. StatPearls. Updated February 4, 2021. Accessed February 17, 2022.

^4.1 PL 104-109– Health Insurance Portability and Accountability Act of 1996. GovInfo.. Accessed February 17, 2022.

^5.2 Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification rules under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; other modifications to the HIPAA rules. Fed Regist. 2013;78(17):5565–5702.

^6.1 Adler-Milstein  J, Holmgren  AJ, Kralovec  P, Worzala  C, Searcy  T, Patel  V. Electronic health record adoption in US hospitals: the emergence of a digital “advanced use” divide. J Am Med Inform Assoc. 2017;24(6):1142–1148. [IIIB]