The secondary tool utilized to support the development of this project was a literature review. During the surveying phase, Kristi and I consumed ourselves with research. We are both invested Clinical Nurse's dedicated to discovering sound and specific literature to support and build our individual nursing practices. It is because of this dedication, we also chose to seek out current resources to relay and rationalize best practices throughout our teaching standard tool.
Searching for current professional literature and evidence based practice related to electronic documentation requirements rendered scarce results. Our search results revealed that electronic documentation is still transitioning into customary practice throughout the healthcare industry and therefore limited research has been conducted and reviewed, especially concerning intraoperative documentation recommendations. Due to this limitation, Kristi and I resourced our leading professional organization, the Association of Operating Room Nurses (AORN) as a primary reference for professional recommended practices.
AORN is a non-profit membership association that represents the interests of perioperative nurses by providing nursing education, standards, and clinical practice resources. AORN appraises Guidelines for Perioperative Practice (previously known as Recommended Practices) to streamline best practice principles. Kristi and I elected to review the most current AORN Recommend Practices and to utilize the document as a primary resource in backing the teaching standard. At the time, AORN offered nine recommend practices related to electronic documentation standards. Kristi and I both assumed the responsibility of reviewing the entire text, however, we divided the task of authoring condensed notes of the recommendations. Kristi assumed the first four recommendations as I took on the recommendations V-IX. The link and documents below include the AORN Recommendations and the finalized condensed notes of all nine recommendations. Again, the recommendations that I reviewed and completed the condensed notes for include AORN Recommended Practices V-IX.
Searching for current professional literature and evidence based practice related to electronic documentation requirements rendered scarce results. Our search results revealed that electronic documentation is still transitioning into customary practice throughout the healthcare industry and therefore limited research has been conducted and reviewed, especially concerning intraoperative documentation recommendations. Due to this limitation, Kristi and I resourced our leading professional organization, the Association of Operating Room Nurses (AORN) as a primary reference for professional recommended practices.
AORN is a non-profit membership association that represents the interests of perioperative nurses by providing nursing education, standards, and clinical practice resources. AORN appraises Guidelines for Perioperative Practice (previously known as Recommended Practices) to streamline best practice principles. Kristi and I elected to review the most current AORN Recommend Practices and to utilize the document as a primary resource in backing the teaching standard. At the time, AORN offered nine recommend practices related to electronic documentation standards. Kristi and I both assumed the responsibility of reviewing the entire text, however, we divided the task of authoring condensed notes of the recommendations. Kristi assumed the first four recommendations as I took on the recommendations V-IX. The link and documents below include the AORN Recommendations and the finalized condensed notes of all nine recommendations. Again, the recommendations that I reviewed and completed the condensed notes for include AORN Recommended Practices V-IX.
Please select the link below to connect and review the AORN Guidelines for Perioperative Practice: Guideline for Health Care Information Management
aorn_recommended_practices_i-iv.docx | |
File Size: | 19 kb |
File Type: | docx |
aorn_recommended_practices_v-ix.docx | |
File Size: | 20 kb |
File Type: | docx |
Literature Review Continued...
While the AORN Recommended Practices were a vital resource that facilitated the initial phases of developing the teaching standard, additional resources were required and rightfully referenced to support documentation practices in several subsections of the intraoperative chart. Kristi and I utilized professional resources, such as the Health Sciences Library catalogs to access supplementary sources and to conduct an extended literature review. We also utilized existing hospital Policies & Procedures/Guidelines as supportive resources to the document as well.
Kristi and I utilized these additional references in order to review and include best practice expectations throughout the teaching standard. For equality purposes, Kristi and I equally divided the Op-Time subsections and chose to review our sections separately. Dividing these subsections allowed us to equally contribute to the document. The document below references the additional resources that were examined and conveyed throughout the teaching standard tool, including levels of evidence. The UCH Policies we referenced and included as backing and rationale for the documentation in the teaching standard are also attached below.
Kristi and I utilized these additional references in order to review and include best practice expectations throughout the teaching standard. For equality purposes, Kristi and I equally divided the Op-Time subsections and chose to review our sections separately. Dividing these subsections allowed us to equally contribute to the document. The document below references the additional resources that were examined and conveyed throughout the teaching standard tool, including levels of evidence. The UCH Policies we referenced and included as backing and rationale for the documentation in the teaching standard are also attached below.
teaching_standards_intraoperative_epic_documentation_references.docx | |
File Size: | 16 kb |
File Type: | docx |
specimen_integrity-uch.docx | |
File Size: | 76 kb |
File Type: | docx |
surgical_counts-uch.docx | |
File Size: | 81 kb |
File Type: | docx |