What is the required or recommended nursing documentation for patients in the pre-operative and post-operative phases?

(Santos)

Santos Almeida, A. C., et al  (2021). Inadequate completion of surgical data for patient safety: opinion of health professionals. Rev Rene, 22(1), 1–8. Free Full Text

Grommi, S., et al (2021). Educating Registered Nurses for Pain Knowledge and Documentation Management: A Randomized Controlled Trial. International Journal of Caring Sciences, 14(2), 919–929. Full Text for Emory Users

Lakshmikantha, N., & Lakshman, K. (2021). A Review of Operation Theater Notes in a Tertiary Care Center. Indian Journal of Surgery, 83(4), 956–959. Full Text for Emory Users

Shoqirat, N., et al  (2019). Nursing Documentation of Postoperative Pain Management: A Documentary Analysis. Journal of Nursing Care Quality, 34(3), 279–284. Full Text for Emory Users

Discharge lounges and patient/system outcomes

“The development of the discharge lounge has demonstrated significant improvement in five areas:
• Higher patient satisfaction scores
• Increased patient discharges by 2:00 p.m. daily
• Reduced boarding time, or the time patients spend in the ED before being transferred to another unit
• Decreased frequency of 30-day readmissions
• Enhanced identification and correction of potential safety issues”

(Rhodes)

RHODES, J. R., et al (2020). Discharge lounges for optimal outcomes: A quality improvement project. Nursing, 50(12), 65–68.
Full Text for Emory Users

Continue reading

Acuity tools for balanced nurse-patient assignments

“The use of objective, electronically generated nursing workload scores, combined with traditional nurse-to-patient ratios, provides accurate real-time nurse staffing needs that can inform best practice in staffing.”

Meyer, K. R., et al (2020). Development of a Nursing Assignment Tool Using Workload Acuity Scores. The Journal of nursing administration, 50(6), 322–327.

(Meyer)
Continue reading

Communicating with intubated or tracheostomy through technology

“Surgical procedures that render patients acutely aphonic can cause them to experience significant anxiety and distress. Participants in this study included hospitalized patients who
acutely lost the ability to speak due to tracheostomy or total laryngectomy. Acute loss of phonation arising from surgery can be highly distressing for patients, and use of augmentative technology may alleviate some of these challenges by improving communication.”

Haring, C., Farlow, J., Leginza, M., Vance, K., Blakely, A., Lyden, T., . . . Casper, K. (2021). Effect of Augmentative Technology on Communication and Quality of Life After Tracheostomy or Total Laryngectomy. Otolaryngology–head and Neck Surgery., 019459982110137.
Full Text for Emory Users

Continue reading

Patient participation in recording fluid input/output

“The accurate documentation and maintenance of fluid balance charts constitute an integral part of nursing care. However, inaccuracies in fluid balance charting by nurses often occur. Inaccurate charting can result in delayed interventions, affecting the safety of patients. It has been found that fluid intake charting in an acute surgical inpatient ward is highly inaccurate. Many expressions of dissatisfaction are evident among medical healthcare professionals and patients regarding the accurate updating of the charts. Therefore, evidence-based measures need to be implemented in order to improve the safety of patient care through accurate recording of patients’ fluid intake”

Liaw, Y., & Goh, M. (2018). Improving the accuracy of fluid intake charting through patient involvement in an adult surgical ward: A best practice implementation project. JBI Database of Systematic Reviews and Implementation Reports.,16(8), 1709-1719.
Full Text for Emory Users

Continue reading

Do oncology nurse-navigators (ONN) improve patient outcomes?

Muñoz R, et al.. Multidisciplinary Cancer Care Model: A Positive Association Between Oncology Nurse Navigation and Improved Outcomes for Patients With Cancer. Clin J Oncol Nurs. 2018 Oct 1;22(5):E141-E145.

Muñoz R, Farshidpour L, Chaudhary UB, Fathi AH. Multidisciplinary Cancer Care Model: A Positive Association Between Oncology Nurse Navigation and Improved Outcomes for Patients With Cancer. Clin J Oncol Nurs. 2018 Oct 1;22(5):E141-E145. doi: 10.1188/18.CJON.E141-E145. PMID: 30239520.
Fulltext for Emory Users

Continue reading

How can the medical record be used as an effective tool for patient and clinician communication?

“Electronic medical records comprise management of patients’ care, the clinical data repository, order entry and clinical decision suppor. EMRs can contain various components, including patient portals, secure messaging, and computerized physician order entry.”  “Clear communication is important to ensure safe and effective patient care in hospital settings. The adoption of EMRs in hospitals affects the ways in which health professionals communicate with patients and families.”

Manias, E.,et al E. (2020). Patient and family engagement in communicating with electronic medical records in hospitals: A systematic review. International Journal of Medical Informatics., 134, 104036.
Full Text Access for Emory Users
Continue reading