Utilizing a Standardized Language in an EHR to Collect Data for Quality Programs, Research, and Reporting

Purpose:
To enable significant and measurable improvements in Perioperative patient care through a transformed electronic documentation process leading to improved quality and safety of care. The EHR provides us the data to monitor quality and safety.

Significance:
Consistent application of a standardized language, such as the Perioperative Nursing Data Set, is essential for gathering data to compare the effectiveness of nursing interventions on patient outcomes.

Strategy and Implementation:
Currently EHRs are customized with each installation. This customization leads to discrepancies in data collected as well as discrepancies in data metrics. The use of a standardized nursing language transforms electronic documentation at the bedside making it more consistent and complete. The nursing workflow that includes assessment, nursing diagnosis, interventions, evaluation and outcomes provides the pathway for logical application of a clinically relevant recognized nursing language (PNDS) in the EHR. With PNDS as the foundation following the perioperative nursing workflow the EHR becomes a more effective tool for the collection of data for evaluation of the impact of nursing intervention on patient outcomes. A standardized approach to documentation enables aggregation of comparable data from multiple facilities for research that can be generalized more widely.

Evaluation:
The data collected as well as the metrics will be evaluated with user input and changes made to improve reliability and validity of data.

Implications for Practice:
Research on the impact of nursing interventions in the surgical setting is lacking. Mapping PNDS in the EHR sets in motion a process by which data on perioperative nursing practice can be used to increase the evidence on which practice is based.