Teaching Standard:
AIP Intraoperative EPIC Documentation
A secondary Policy&Procedure/EBP Initiative I chose to co-lead and partake in was the creation of OR Documentation Guidelines. This project also evolved from its original Guideline format into a Teaching Standard, however, this project was essential and validates the style of leadership that I proactively provide on my unit.
The Operating Room (OR) is a highly specialized practice area with unique care interventions and patient care experiences that require precise documentation. Accuracy in OR documentation is essential in order to best reflect care and assess and/or plan a patient's future care interventions related to the intraoperative experience. Therefore, a certain level of standardization with documentation helps support both the intraoperative staff with organization and productivity as well as supports post-operative staff with continuity of care and collective rationale for patient care interventions.
The AIP OR staff recognized a wide variance and disagreement in charting practices both between services and individual staff practices on the unit. This discourse generated conversation and recognized a need for structure and regulation in documentation practices. This conversation took form and was put into motion through endorsement as an essential project for both patients' safety as well as for continuity of documentation practices on the unit. Kristi Scheuessler BSN, RN, CNOR and I proactively accepted the challenge to collaborate and create OR documentation guidelines in order to provide the OR staff with standardization and supply our patients with a safer method of communicating care requirements. The partnership Kristi and I developed was supported through an extensive and ranging group of stakeholders including OR leadership, Education, EPIC specialists, Patient Safety specialist, Clinical Scholars and Risk Management personnel. This team collaborated to help review and revise the original guideline work and ultimately supported the transition from intended guideline into a teaching standard resource for both OR staff and EPIC trainers.
Support for this project was resourced primarily through staff suggestions via survey. The secondary resource utilized was a literature review of current Association of Operating Room Nurses (AORN) Recommended Practices concerning documentation practices. The third resource utilized was the expert-opinions of the inclusive stakeholder group. These three tools were the primary resources utilized by Kristi and I to successfully review, revise and create the Teaching Standard: Intraoperative EPIC Documentation resource tool.
Kristi and I took the initiative to coordinate several meetings to review survey results as well as each section and subsection of the intraoperative chart with the stakeholders group. These meetings facilitated the growth and development of the teaching standard tool as well as supporting connections with other healthcare professionals outside the group of stakeholders. These healthcare professionals were utilized as secondary resources to assure the document's content was both accurate and conclusive amongst all care practice areas that both review and integrate with Op-Time documentation.
Successively, Kristi and I began reviewing the intraoperative chart. The current formatting of Op-Time divides the chart into three sections, Pre-Incision, Procedure and Closing. Each of these three sections also has subsections that require specific analysis. Kristi and I chose to divide these subsections equally to review and to author appropriate teaching standards for. By dividing these sections, Kristi and I dominated drafting an inclusive document to regulate documentation practices of the OR RN through the identification and clarification of Op-Time documentation criteria.
Kristi and I collaborated to draft four documents. Each draft was subsequently reviewed by members of the stakeholder's group. The stakeholders analyzed the drafts to assure the essential content and modifications of documentation practices were addressed. It was during review of the drafts that the stakeholder's identified that the primary scope and purpose of this document was ultimately a teaching standard tool and did not directly correlate with outlined UCH requirements for Guideline submission. As such, Kristi and I referenced the Nursing Practice Guidelines Committee as a secondary source to review and categorize the document. The committee agreed and addressed that the document did not need to come to group for approval but would best serve as teaching standard document. With such review, the final manuscript of the teaching standard tool was completed and distributed to the stakeholder's for approval via Outlook e-vote. The approval was unanimous.
With the approval, Kristi and I then began to coordinate a comprehensive plan to implement, present and educate OR staff to the teaching standard tool. Kristi and I collaborated to upload the document to the unit's Weebly education site as well as connecting with unit leadership to file a hard copy at the unit's control desk. Kristi and I also organized and scheduled an opportunity to formally present the teaching standard tool at a staff meeting in August 2015 to assure staff members have the opportunity to receive rationale for documentation practice changes and also for staff to ask questions and review concerns related to the tool.
Overall, the process of reviewing staff practices, researching professional and evidence-based practices and creating standardized Op-Time documentation practices was an extensive and valuable project. I found myself invested in this process and project because I understand and believe in the difference it will make for both patients and nursing professionals alike. I significantly enjoyed collaborating with Kristi as well as the stakeholders group throughout this project. They all provided me with new awareness of the importance of documentation. They also helped support my passion as to why this project was so necessary and how it will remain as a primary educational resource for both OR staff and EPIC trainers.
Kristi and I plan to collaborate in the future with survey follow up post teaching standard implementation and education in August 2015. We have also already discussed development of additional documentation tools including a "Tips Sheet" with more detailed Op-Time recommendations including EPIC keystrokes and EPIC Downtime procedures. Despite the transition from intended guideline to teaching standard, this document remains an essential and effective tool to directly support safe and organized patient care through standardized documentation practices.
The Operating Room (OR) is a highly specialized practice area with unique care interventions and patient care experiences that require precise documentation. Accuracy in OR documentation is essential in order to best reflect care and assess and/or plan a patient's future care interventions related to the intraoperative experience. Therefore, a certain level of standardization with documentation helps support both the intraoperative staff with organization and productivity as well as supports post-operative staff with continuity of care and collective rationale for patient care interventions.
The AIP OR staff recognized a wide variance and disagreement in charting practices both between services and individual staff practices on the unit. This discourse generated conversation and recognized a need for structure and regulation in documentation practices. This conversation took form and was put into motion through endorsement as an essential project for both patients' safety as well as for continuity of documentation practices on the unit. Kristi Scheuessler BSN, RN, CNOR and I proactively accepted the challenge to collaborate and create OR documentation guidelines in order to provide the OR staff with standardization and supply our patients with a safer method of communicating care requirements. The partnership Kristi and I developed was supported through an extensive and ranging group of stakeholders including OR leadership, Education, EPIC specialists, Patient Safety specialist, Clinical Scholars and Risk Management personnel. This team collaborated to help review and revise the original guideline work and ultimately supported the transition from intended guideline into a teaching standard resource for both OR staff and EPIC trainers.
Support for this project was resourced primarily through staff suggestions via survey. The secondary resource utilized was a literature review of current Association of Operating Room Nurses (AORN) Recommended Practices concerning documentation practices. The third resource utilized was the expert-opinions of the inclusive stakeholder group. These three tools were the primary resources utilized by Kristi and I to successfully review, revise and create the Teaching Standard: Intraoperative EPIC Documentation resource tool.
Kristi and I took the initiative to coordinate several meetings to review survey results as well as each section and subsection of the intraoperative chart with the stakeholders group. These meetings facilitated the growth and development of the teaching standard tool as well as supporting connections with other healthcare professionals outside the group of stakeholders. These healthcare professionals were utilized as secondary resources to assure the document's content was both accurate and conclusive amongst all care practice areas that both review and integrate with Op-Time documentation.
Successively, Kristi and I began reviewing the intraoperative chart. The current formatting of Op-Time divides the chart into three sections, Pre-Incision, Procedure and Closing. Each of these three sections also has subsections that require specific analysis. Kristi and I chose to divide these subsections equally to review and to author appropriate teaching standards for. By dividing these sections, Kristi and I dominated drafting an inclusive document to regulate documentation practices of the OR RN through the identification and clarification of Op-Time documentation criteria.
Kristi and I collaborated to draft four documents. Each draft was subsequently reviewed by members of the stakeholder's group. The stakeholders analyzed the drafts to assure the essential content and modifications of documentation practices were addressed. It was during review of the drafts that the stakeholder's identified that the primary scope and purpose of this document was ultimately a teaching standard tool and did not directly correlate with outlined UCH requirements for Guideline submission. As such, Kristi and I referenced the Nursing Practice Guidelines Committee as a secondary source to review and categorize the document. The committee agreed and addressed that the document did not need to come to group for approval but would best serve as teaching standard document. With such review, the final manuscript of the teaching standard tool was completed and distributed to the stakeholder's for approval via Outlook e-vote. The approval was unanimous.
With the approval, Kristi and I then began to coordinate a comprehensive plan to implement, present and educate OR staff to the teaching standard tool. Kristi and I collaborated to upload the document to the unit's Weebly education site as well as connecting with unit leadership to file a hard copy at the unit's control desk. Kristi and I also organized and scheduled an opportunity to formally present the teaching standard tool at a staff meeting in August 2015 to assure staff members have the opportunity to receive rationale for documentation practice changes and also for staff to ask questions and review concerns related to the tool.
Overall, the process of reviewing staff practices, researching professional and evidence-based practices and creating standardized Op-Time documentation practices was an extensive and valuable project. I found myself invested in this process and project because I understand and believe in the difference it will make for both patients and nursing professionals alike. I significantly enjoyed collaborating with Kristi as well as the stakeholders group throughout this project. They all provided me with new awareness of the importance of documentation. They also helped support my passion as to why this project was so necessary and how it will remain as a primary educational resource for both OR staff and EPIC trainers.
Kristi and I plan to collaborate in the future with survey follow up post teaching standard implementation and education in August 2015. We have also already discussed development of additional documentation tools including a "Tips Sheet" with more detailed Op-Time recommendations including EPIC keystrokes and EPIC Downtime procedures. Despite the transition from intended guideline to teaching standard, this document remains an essential and effective tool to directly support safe and organized patient care through standardized documentation practices.