1. SIMPLE PNDS Education Design by: Marisa Tapia MSN RN ACNS-BC

3. Hi Nancy, my name is Amelia I am the Informatics Nurse that will guide you through this tutorial We’ll start with what does the PNDS stand for

4. The PNDS stands for: P Perioperative N Nursing D Data S Set

5. Okay… but what IS the PNDS?

6. The PNDS reflects the perioperative clinical workflow which captures the perioperative nurse’s contributions to the patient outcomes via clinical documentation in the electronic health record

8. The PNDS language is a computer coded language built into the electronic record for Perioperative Nurses to capture the nurse’s documented data

10. In simple terms… Whatever YOU enter into the electronic health record related to patient care, will be captured using the PNDS codes within the computerized program your facility uses.

11. So let me get this right…..

12. 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

13. Am I on the right track?

14. ITS IMPORTANCE 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 versus non-clinical variables or values such as turnover time.

15. That is correct!

17. The PNDS includes computerized codes which will facilitate consistent electronic documentation, quality initiative identification, and clinical reporting in the perioperative setting.

18. Let’s Review

19. DEFINITION The PNDS is a standardized vocabulary that describes perioperative nursing practice by providing formal definitions when the nurse is documenting the care being provided to the patient in surgery.

20. Better said: It is a standardized and controlled vocabulary that EVERY perioperative nurse uses to identify the work being done in the perioperative area when documenting or “charting” in the Electronic Healthcare Record (EHR).

21. I GET IT!!!!!

22. I GET IT!!! A standardized single concept that will capture every step, skill, and care the perioperative nurse provides to the patient undergoing an operative or invasive procedure when documenting care in the Electronic Health Record (EHR)

23. YOU GOT IT!!!!

24. But..what’s in it for me, more work?

25. I already have too much to do and now this?

27. The PNDS will not make more work for you. The PNDS will itemize what you do for the care you provide for each patient.

28. THE PNDS WILL IDENTIFY THE TRUE VALUE OF THE WORK THAT NURSES PROVIDE WHEN CARING FOR THE PATIENT IN SURGERY.

29. PNDS captures the essence of caring… for the patient

30. The PNDS uses the nursing process as the foundation for the documentation in the electronic health record

32. Finally…they will understand what I do as a nurse in the perioperative setting!!!

33. The true value of what the RN does! The PNDS provides the documented value, cost-effectiveness, and contributions of professional nurses in the perioperative setting while gathering reliable perioperative data for future research related to perioperative nursing.

34. From admission….

35. …to documenting the care provided by the nurse in surgery….. Click to save

36. Positive Patient Outcome PNDS captures all the data for this patient’s surgery and the care he received GOAL MET

38. The PNDS is a computerized method to collect data to measure CLINICAL IMPACT as well as non- clinical variables/values such as turnover time Let’s Recap:

40. Measuring turnover times of the room for the next case, although important at times, is not a measure of clinical nursing quality but a measure of efficiency (non-clinical processes) .

41. The PNDS is…

42. A method to document the value, cost-effectiveness, and the contributions ofprofessional nurses that are providingcare to the patient undergoing a surgical intervention…

43. Isn’t that what we are supposed to be doing?

44. My nursing interventions matter!

45. The work I do will now be captured, collected, validated and…..

46. My work will be studied….and

47. My work will provide the data for new evidence in practice

48. I get that the PNDS provides great value but….what can be gained from the PNDS?

49. From this To this

50. 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 establish data for best practices.

51. What will all this stuff generate?

53. HOW is it done?

55. The information collected from the PNDS captures the nurse’s interventions which provide reliable perioperative data for nursing research.

57. Perioperative practice visibility by the data being generated reflecting the clinical work flow.

58. Records reliable and valid perioperative data

59. Allows for the comparison of the data being captured to compare effectiveness, efficiency

62. Patient-centered care

63. Evidence-based practice

69. Basic Elements of how it is identified in the Electronic Health Record

70. Are You still with me?

71. Following you so far….

72. Let me give you an example

73. Now, how would it look like when I am documenting the nursing interventions or the work that I do ?

75. But where is the PNDS?

76. The PNDS has built in codes In the Electronic Healthcare Record (EHR) that you don’t See in practice but they are there. I will show you an example

77. PNDS Codes are the data points that when you document will be captured and used for nursing quality outcomes

79. Now my nursing care will be recognized in research studies, in evidence based practice and in nursing quality outcomes

80. YOU GOT IT! Let’s Celebrate Your Success!

81. You have earned 1.5 Contact Hours of Continuing Education