Perioperative Education Documentation for Certified Perioperative Nurse (CNOR)

Perioperative Education Documentation

Guidelines:

• Preoperative patient education can reduce a patient’s anxiety, reduce perception of postoperative pain, shorten the length of hospital stay, and improve satisfaction with health care.
• Perioperative education:
  • Can occur pre-operatively, intraoperatively (for procedures without general anesthesia), and post-operatively
  • Adequate perioperative education can impact patient outcomes such as pain, anxiety, mobility, and function
  • Documentation of perioperative education should follow organization policy

Considerations:

• Main areas of education need:
  • Information: verifying that the surgeon explained and patient understood the surgical procedure, perioperative policy and procedure, and the medications that will be used during and after the surgery, including potential adverse reactions.
  • Psychosocial: concerns include the expected length of the procedure and issues related to the patient’s previous surgical experiences, such as problems with anesthesia. Alleviate fears of patient/family
  • Skill training: teaching about the use of equipment and demonstrating activities that the patient may be asked to complete postoperatively. Deep breathing and coughing, incentive spirometry, and using pain intensity rating scale. Give instructions in preferred language, using terms that are concise and easy to understand. Reinforce with written material if possible
  • Follow facility’s policy to document what the patient/family were taught and their responses to that education

Nurse’s role:

• Provide appropriate perioperative patient/family education
• Prepare patient/family for what they will see, hear, feel, smell, and experience in each perioperative setting
• Alleviate fear and anxiety
• Promote patient safety

Pitfalls:

• Liability
  • Documentation of perioperative education protects you and your facility from liability if legal problems arise
  • Patient documentation is a legal record so nurses should avoid pre-charting which can result in inappropriate descriptions of patient care and require subsequent modification

Examples:

• Pediatric surgical patients, mask induction

Linchpins (Key Points):

• The perioperative nurse may provide patient/family education pre-operatively, intraoperatively, and postoperatively
• The goal of perioperative education is to promote patient safety and optimal outcomes
• Document perioperative education per organization policy