12. A nursing language Not a computer program A method to document and collect perioperative nursing care data to evaluate nursing care to determine evidence based practice Let me show you…
14. The PNDS codes capture the documentation of the care the nurse provide in the operating room to their patients in the electronic health record. Click to save
16. Why relevant? The PNDS is an approved ANA (American Nurses Association) nursing language that provides a true perioperative standardized method of documentation to gather data in order to measure clinical impact versusnon-clinical variables or values such as turnover time (measurement of efficiency not nursing care).
23. DEFINITION The PNDS is a standardized vocabulary that describes perioperative nursing practice by providing formal definitions when the nurse is documenting the care provided to the patient in surgery via the electronic healthcare record (EHR)-The “charting”.
29. The PNDS uses the nursing process as the foundation for the documentation in the electronic health record
30. Correctly using this While providing this And documenting this… Will avoid this….
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32. The RN in surgery: ROI The PNDS provides the documented value, cost-effectiveness, and the contributions of professional nurses in the perioperative setting while gathering reliable perioperative data for future research related to perioperative nursing care.
44. Additionally, The care that is documented will be collected and is retrievable via the PNDS codes for data analysis and quality measures, such as SCIP and nurse sensitive patient outcomes (NDNQI) which will provide the evidence for best practices.
58. Surgical Counts: Every step will be documented from opening the sterile instruments, checking sterility, to performing the instrument count, separating sponges to performing a sponge count, to identifying items to be included in the surgical count.
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60. The PNDS includes computerized codes which will facilitate consistent electronic documentation, quality initiative identification, and clinical reporting in the perioperative setting that will be built into the program your facility purchases.
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62. PNDS has built in codes. These codes are the data points that when you document the care YOU provide, will be captured and used for nursing quality outcomes via the computer program your facility purchases.
63. Now the nursing care will be recognized in research studies, in evidence based practice and in nursing quality outcomes