Postoperative Follow-up for Certified Perioperative Nurse (CNOR)
Included In This Lesson
Outline
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
- Documentation of all nursing interventions, including patient education
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
- Telephone
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
Transcript
References
- Irarrázaval, M.J., Inzunza, M., Muñoz, R. et al. (2021). Telemedicine for postoperative follow-up, virtual surgical clinics during COVID-19 pandemic. Surg Endosc, 35, 6300–6306.https://doi.org/10.1007/s00464-020-08130-1
- Guideline for patient information management. (2023). In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc. In press.
NCLEX
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