Patient Records and Care Documentation for Certified Perioperative Nurse (CNOR)
Patient Records and Care Documentation Guidelines: The perioperative nurse maintains accurate patient records/documentation of all care provided Documentation per healthcare organization policy and state/federal regulatory and accreditation requirements Complete, accurate, timely Considerations: Healthcare records should maintain a complete, comprehensive, and accurate description of concurrent, ongoing, and transitional perioperative care The operative record is […]
Interdisciplinary Healthcare Team Collaboration for Certified Perioperative Nurse (CNOR)
Interdisciplinary Healthcare Team Collaboration Guidelines: Find a way to “yes” The best interest of the patient prevails Identified and discuss before start of case Huddle Historical data may help scrutiny Considerations: Clarify/need objective Risk/benefit include patient where possible cost/benefit Committee (ethics, practice) guidance should be found in policy Nurse’s role: Voice identified […]
Patient Status Communication for Certified Perioperative Nurse (CNOR)
Patient Status Communication Guidelines: The perioperative nurse communicates current patient status to interdisciplinary team Facilitates interdisciplinary team care coordination Follow policy and regulatory guidelines Utilize standardized communication tools Considerations: Communication and teamwork is a perioperative nursing safety issue Hand-off/Handover protocols improve communication in the perioperative setting Checklists enhance meaningful communication and teamwork With […]
Communication of Patient Outcomes (Continuum of Care) for Certified Perioperative Nurse (CNOR)
Communication of Patient Outcomes (Continuum of Care) Guidelines: SBAR Report to PACU always Standardized “Read back” method Call ahead before transfer Especially ICU Transfer is inherently risky Updating family – facility policy Considerations: Pathway to handoff – ICU Necessary equipment Vent Warmer Parents Most relevant information first Nurse’s role: Updates to family […]
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, […]
Postoperative Follow-up for Certified Perioperative Nurse (CNOR)
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 […]
Perioperative Assessment Documentation for Certified Perioperative Nurse (CNOR)
Perioperative Assessment Documentation Guidelines: The perioperative RN documents activities to record a description of the care provided to patients in the surgical setting Transfer of information from the perioperative environment throughout the care continuum Identification of pre-existing versus surgically-acquired injuries Wounds Pressure injuries SSIs Follows the nursing process framework for perioperative nursing care Assessment, […]
Transfer of Care Documentation for Certified Perioperative Nurse (CNOR)
Transfer of Care Documentation Guidelines: Interdisciplinary communication in the OR is essential for efficient, effective, and successful patient care Communication includes: Documentation Communication of the activities that took place in the OR Also includes critical information about patient and procedure Allows for continuity of care Transfer of Care/Handover Communication A process and documentation form […]
Implant Records and Tracking for Certified Perioperative Nurse (CNOR)
Implant Records and Tracking Guidelines: United States Food and Drug Association (FDA) requires strict guidelines in properly documenting and tracking implants Documentation should included in, but not limited to: Patient’s permanent record Patient’s operative record Implant registry maintained by the OR Implant registry includes: Lot # Serial # Manufacturer Size Type Anatomic position of […]
Patient Status Evaluation (Transfer of Care) for Certified Perioperative Nurse (CNOR)
Patient Status Evaluation (Transfer of Care) Guidelines: The perioperative nurse evaluates patient status to facilitate transfer of care PACU ICU home Evaluation is an ongoing process throughout perioperative patient care The perioperative nurse should utilize standardized handoff communication and reports Patient safety Team communication Essential, up-to-date, and specific information Reduces errors/omissions Considerations: TJC, […]