Postoperative Follow-up

Guidelines:

• The perioperative RN should communicate and document postoperative follow-up
  • Documentation of all nursing interventions, including patient education
    • May not be providing the actual discharge follow-up communication, but responsible for communicating important information to the team and in handover in order to promote patient safety and optimal outcomes
  • Proper use of documentation tools
    • EHR, downtime forms, implant records, incident/adverse events reports
    • Scripts for postoperative follow-up
  • Patient postoperative follow-up communication within regulatory guidelines and per facility policy
    • HIPAA compliance

Considerations:

• Types of postoperative follow-up:
  • Telephone
    • Postoperative follow-up phone calls
    • Typically done by pre-op or PACU RNs
    • Facility dependent, may be done by OR RNs
    • Call scripts ensure consistency and thorough encounter
  • Telemedicine
    • Use of electronic information and video communication technologies
    • Increasingly being used and becoming promising tool in healthcare
    • Excellent clinical outcomes, enhanced patient satisfaction, increased accessibility, reduced cost and reduced waiting times
    • For appropriate patients, this can be done in place of an in-person clinic visit for follow up
  • In-Person
    • Clinic appointment for follow-up per discharge instructions
    • Post-operative rounding for surgical patients admitted to the hospital after procedure

Nurse’s role:

• Provide patient/family education/instructions throughout the perioperative experience
  • Reinforcing important instructions for discharge and recovery
  • Provide both written and verbal instructions when possible
  • During assessment, determine any barriers to learning or postoperative follow-up instructions that need to be addressed by the team prior to transfer or discharge
• Participate in postoperative follow-up per facility policy
  • Promote patient safety and optimal outcomes by ensuring questions/concerns are addressed in a timely manner
• Document postoperative follow-up and education per facility policy
• Team communication
  • PACU RN handover with important postoperative instructions
  • Surgical team briefing/debriefing on any barriers to learning or special discharge follow-up needs
  • Perioperative staff information sharing to improve processes with information collected during postoperative follow-up

Pitfalls:

• Postoperative Follow-up communication should be:
  • HIPAA compliant
  • Follow regulatory guidelines and facility policies
  • Allow the opportunity for questions/clarifications (Two-way communication)
  • Supplemented with written instructions when possible
  • Documented accurately and thoroughly
    • Liability
    • Tests pending at discharge

Examples:

• Patient/Family Encounter: Intact, do not Retract!

Linchpins (Key Points):

• The perioperative nurse is the ultimate patient advocate
• The perioperative nurse maintains patient privacy and confidentiality
• The perioperative nurse provides postoperative follow-up information either directly to the patient/family or through RN-RN handover
• The perioperative nurse follows facility policy when providing and documenting postoperative follow-up to patient/family