These recommended practices provide guidelines to assist perioperative nurses in documenting nursing care in the perioperative practice setting. Documentation using the nursing process should be completed for each surgical and other invasive procedure. The nursing process is a formalized systematic approach to providing and documenting patient care. Perioperative documentation is essential for the continuity of goal-directed care and for comparing achieved patient outcomes to expected patient outcomes.

The patient's record should reflect the perioperalive patient's plan of care, including assessment, diagnosis, outcome identification, planning, implementation, and evaluation.

1. Documentation should include information about the status of the patient, nursing diagnoses and interventions, expected patient outcomes, and evaluation of the patient's response to perioperative nursing care. The nursing process provides the governing framework for documenting perioperative nursing care. When the nursing process is used in perioperative practice settings, it demonstrates the critical- thinking skills practiced by the nurse in caring for the surgical patient.'

2. The patient's record should reflect an assessment (ie, physical, psychosocial, cultural, spiritual) performed by the perioperative nurse before surgical or other invasive procedures. A documented assessment forms a baseline for developing nursing diagnoses and planning patient care. Continuing this assessment hroughout each subsequent phase of the patient's care (ie, intraoperative, postoperative) contributes to continuity of care.

3. The patient's record should reflect the plan of care. The planning process begins when the perioperative nurse identifies nursing interventions that will address the patient's actual or potential risk for health  problems (ie, nursing diagnoses). Documentation facilitates communication among health care team members, promotes continuity of care, and serves as a legal record of care provided. Identifying desired patient outcomes that are individualized, prioritized, measurable, realistic, and obtainable aids in developing the plan of care.

4. The patient's record should specify what nursing interventions were performed and when, where, and by whom during each phase of perioperative care.  The implementation process is a result of assessment and planning using nursing judgment and critical thinking skills. The goals of nursing interventions are to prevent potential patient injury or complications and to intervene/treat actual patient problems. Documenting nursing interventions promotes continuity of patient care and improves communication between health care team members.

5. The patient's record should reflect a continuous evaluation of perioperative  nursing care and the patient's response to applied nursing interventions. The nursing process directs perioperative nurses to evaluate the effectiveness of nursing interventions toward attai fling desired patient outcomes. The evaluation process provides information for continuity of care, performance improvement activities, perioperative nursing research, and risk management. Documentation provides a mechanism for comparing actual versus expected outcomes.

6. Perioperative documentation should include, but not be limited to,

• identification of persons providing perioperative patient care (ie, name, title, signature of person responsible for the care);

• description of patient's overall skin condition on arrival and discharge from the pen- operative suite;

• perioperative patient care planning, including baseline physical, emotional, psychosocial, and cultural data;

• presence and/or disposition of sensory aids and prosthetic devices (eg, eyewear, hearing aids, denture, artificial limbs);

• placement of electrosurgical unit (ESU) dispersive pad and identification of the ESU and setting used during the surgical procedure;

• use of temperature-regulating devices, including identification of the unit and documentation of the patient's body temperature before and after discharge from the perioperative suite;

• placement of electrocardiogram electrodes, blood pressure cuff, oximetry and temperature probes, and other invasive and monitoring devices;

• patient positioning and/or repositioning devices and supports, including immobilization devices used during the surgical procedure;

• placement of tourniquet cuffs, including identification of the unit, pressure settings, and inflation and deflation times;

• location of skin, prep, including prep solution used;

• use of lasers, including identification of the unit, name of surgeon and support staff members, type of laser used, surgical procedure, the lens used, length of time laser was used, and the wattage;

• use of intraoperative x-rays and fluoroscopy and protective devices used (if any);

• patient specimens and cultures taken during the surgical procedure;

• location and type of drains, catheters, wound packing, casting material, and dressings used;

• placement and location of implants (eg, medical devices, synthetic and biologic grafts, tissue, bone), including the name of the manufacturer or distributor, lot and serial numbers, type and size of implant, and expiration dates as appropriate, and other information required by the US Food and Drug Administration;

• placement of radioactive implants, including the time, number, location, and type of radioactive material placed in the patient;

• administration of blood or blood products, medications, irrigation solution, and other solutions to the patient during the perioperative period;

• wound classification;

• anesthesia classification and mode of anesthesia provided;

• documentation of sponge, sharp, and instrument count outcomes as appropriate;

• time of patient discharge, patient status at discharge, patient disposition, and method of transfer;

• any significant or unusual occurrences pertinent to penioperative patient outcomes;

• communication with family members or significant others during the surgical procedure; and

• patient/family teaching provided.

Documentation of all nursing activities performed is legally and professionally important for clear communication, collaboration between health care team members, and continuity of patient care.

Policies and procedures for documenting perioperative nursing care should be written, reviewed periodically, revised as necessary, and be readily available within the practice setting.

1. These recommended practices should be used as guidelines for developing policies and procedures for documentation within the perioperative practice setting. Documentation policies and procedures establish authority, responsibility, and accountability and serve as operational guidelines. An introduction and review of documentation policies and procedures should be included in the orientation and ongoing education of personnel to assist them in obtaining knowledge and developing skills and competencies that will influence perioperative patient outcomes.

2. Every perioperative practice setting uses a formal system of documentation of patient care. Although the method of documenting perioperative nursing care varies among practice settings, documentation forms should include, but not be limited to, the following:

• operative record,

• preoperative patient checklist,

• nurses' notes,

• flow sheets,

• care plans,

• implant records

• laser logs.

The methods selected for documenting penoperative nursing care will be based on the facility's overall philosophy of documentation.  

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