Four Signs Your OR Needs a Documentation Overhaul – And How to Begin

Informatics PNDS Standardized Surgical Scheduling Procedure List AORN Syntegrity

By: Erin Carswell, MBA

Published: 12/3/2024

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Introduction 

Standard EHR content often falls short in supporting the complex needs of surgical patient documentation and scheduling. AORN Syntegrity bridges this gap with perioperative-specific nursing documentation and a robust surgical procedure library mapped to CPT®, ICD-10-PCS®, and SNOMED CT®. With the ability to integrate with most EHR systems, AORN Syntegrity empowers perioperative teams to standardize procedures and documentation, streamline workflows, improve patient outcomes, and reduce costs. 

Are inefficiencies in your OR holding you back? If you’re facing challenges in these four critical areas, your OR could benefit from a documentation overhaul. AORN Syntegrity offers solutions tailored to address these issues, including standardized OR documentation with the PNDS (Perioperative Nursing Data Set), a comprehensive procedure list, and specialty content. 

Sign #1: Frequent Documentation Errors

Frequent issues such as mismatched procedure codes, incomplete documentation, and the improper use of preference cards can create ripple effects throughout the OR. These challenges contribute to scheduling errors, supply disruptions, and delays, ultimately affecting efficiency and revenue. 

Solution:

Streamline your documentation with AORN Syntegrity’s Procedure List. By standardizing procedure codes, you can improve scheduling accuracy, ensure the correct preference card is utilized to prevent delays, and enhance coordination across pre-, intra-, and postoperative phases of care.

Sign #2: Overburdened OR Staff

Perioperative teams are often understaffed and overextended, leading to stress, burnout, and even attrition. Supporting these professionals is essential to preserving their well-being and maintaining high-quality patient care. 

Solution:

Automate redundant documentation tasks with AORN Syntegrity. By focusing on what’s truly required for regulatory compliance and national practice standards, this tool eliminates unnecessary tasks, freeing up nurses to assist where they’re needed most. The result? A happier, more focused team and improved patient care.

Sign #3: Poor Data Accessibility for Decision-Making

In the OR, every second counts. Delays caused by inaccessible information can lead to adverse outcomes, missed opportunities for improvement, and financial losses, all while adding unnecessary stress to your team. 

Solution: 

AORN Syntegrity includes easily accessible hyperlinks to tools like eGuidelines Plus, providing perioperative nurses with instant access to guidelines, documentation standards, and essential resources. This empowers teams to make faster, more informed decisions and enhances overall efficiency.

Sign #4: Challenges with Compliance and Accreditation

In today’s healthcare environment, compliance with regulatory and accreditation standards such as Joint Commission requirements and CMS guidelines is non-negotiable. Yet, without standardized documentation and clear processes, your OR may struggle to meet these benchmarks.

Solution:

AORN Syntegrity simplifies compliance by guiding your team with best practices for documentation, procedure scheduling, and patient centered care. By adopting AORN Syntegrity, your OR can operate at the highest level of compliance, reducing risk and enhancing your facility's reputation for quality care.

How to get started:

  1. Audit your current documentation practices to identify inefficiencies and gaps. Consider utilizing AORN Syntegrity’s Fee-for-Service auditing to gain expert insights into areas for improvement. 

  1. Collaborate with your OR team to understand their specific pain points and goals. 

  1. Explore AORN Syntegrity solutions to address inefficiencies and align with best practices. 

  1. Partner with the AORN Syntegrity team to develop a phased implementation plan, focusing on high-priority areas first. 

  1. Provide comprehensive training for your team and establish ongoing feedback loops, with AORN Syntegrity offering guidance and support. 

If you’re ready to improve OR efficiency, reduce staff burnout, and elevate patient care, it’s time to explore how AORN Syntegrity can transform your perioperative practices. 

Book a 15-minute call with our team to start the conversation about implementing AORN Syntegrity at your organization or visit aorn.org/syntegrity to learn more. 

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