SIMPLE PNDS

Education Design by: Marisa Tapia MSN RN ACNS-BC

We’ll start with what does the PNDS stand for ?

PNDS

PN

DS

Perioperative

Set

Nursing

Data

WHY use it?

Clarity, preciseness, and consistency in the documented care given

Ensures visibility by the data being generated reflecting the clinical work flow.

Record keeping of perioperative data Compare data being captured for

effectiveness and efficiency PNDS codes are built into the

electronic health record (EHR) allowing you to document care that is safe

Here are some reasons

This is about the charting the nurse does…

The

PNDS is…

A nursing language

Not a computer program

A method to document and collect perioperative nursing care data to evaluate nursing care to determine evidence based practice

Let me show you…

PerioperativeClinical Workflow

Perioperative Clinical Documentation

Optimal Patient Outcome

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

Moving on to 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 (measurement of efficiency not nursing care).

Why relevant?

This will produce…

•Documented data•Provide solid evidence•Promote practice guidelines•Generate outcomes that will promote:• Evidence Based

Practice• Benchmarking

Let’s Review

The PNDS is a standardized vocabulary that describes perioperative nursing practice by providing formal definitions when the nurse is documenting the care provided to the patient in surgery via the electronic healthcare record (EHR)-The “charting”.

DEFINITION

Will it create more work?

Nurses have so much to do already, adding one more thing could cause harm to the patient…

The PNDS will not make more work for you or harm the patient.

The PNDS will itemize what you do for the care you provide for each patient.

PNDS: Identifies the true value of the work the nurse provides during the care of the patient in surgery

PNDS captures the essence of caring…

for the patient

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

Correctly using this

While providing this And documenting this…

Will avoid this….

The PNDS provides the documented

value, cost-effectiveness, and the

contributions of professional nurses in

the perioperative setting while gathering

reliable perioperative data for future

research related to perioperative

nursing care.

The RN in surgery: ROI

From admission….

…to documenting the care provided by the nurse in surgery…..

Click to save

Turnover time is not a measurement of nursing care or nursing quality but rather a measurement of efficiency

…it documents the value of professional nurses providing care to the patient undergoing a surgical intervention…

Isn’t that what NURSES are supposed to be doing?

The work Nurses do in the operating room will now be captured, collected, validated and…..

…studied…but….

What can be gained from the PNDS?

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 provide the evidence for best practices.

Researched and tested

Start with this To get to

this

What will all this stuff generate?

But….

From this To this, for the

perioperative specialty

Resulting in this

•Quality Measures •Patient-centered care activity•Evidence-based practice guidelines•Performance-driven outcomes

PNDS identifies and generates:

Putting it all together…..

Let me give you an example

Surgical Counts:Every step will be documented from opening the sterile instruments, checking sterility, to performing the instrument count, separating sponges to performing a sponge count, to identifying items to be included in the surgical count.

The PNDS includes computerized codes which will facilitate consistent electronic documentation, quality initiative identification, and clinical reporting in the perioperative setting that will be built into the program your facility purchases.

PNDS has built in codes. These codes are the data points that when you document the care YOU provide, will be captured and used for nursing quality outcomes via the computer program your facility purchases.

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

So don’t practice like this…

Or else…

This

Will lead to this

Use this

With this

To gain this…

Positive Patient Outcome

PNDS captures all the data for this patient’s surgery and the care he received

GOAL MET

ResourcesSlide 5 HUH http://krapps.com/2009/07/13/mischief-lure-drawing-iphone-app/ Slide 7 and 8 Cartoon http://www.nataliedee.com/archives/2009/Jun/Slide 11 Computer Screen Shot http://www.downloadpipe.com/Windows/network-internet-terminal-telnet-clients/review-ZOC-Terminal-SSH-Telnet-Serial-73906.htmlSlide 18 Frustrated nurse http://www.shutterstock.com/pic-13153471/stock-photo-young-nurse-stressed-out-and-upset-at-work.html Slide 20 Focus on Quality http://www.fotolia.com/id/1040805Slide 28 Aha http://femibeckley.blogspot.com/ Slide 29 don’t forget http://www.mikemccready.ca/blog/2009/02/my-new-favorite-blogging-toy-scribefire/ slide 30 Einstein duh http://loanworkout.org/2009/05/can-all-homeowners-get-free-foreclosure-help/ Slide 34 Boy reading http://www.cclibraries.com/index.php/centennial-celebration Slide 56 judge and gavel http://www.memphisinjurylawyerblog.com/divorce/ Slide 57 computer on wheels (COW) http://www.interiormall.com/cat/ndisplaycoll.asp?c1=Furniture&book=1738Slide 10, 26, 27, 30-33, 35, 36, 38, 39, 40, 41- 50, 52, 53, 54, 55, 57 and 58 personal photographs and graphics M. Tapia and AORN .Slides 8, 56 (harm), photographs from Microsoft Office Online http://office.microsoft.com/en-us/clipart/default.aspxSlide 59 Choose the right tool http://webtools4u2use.wikispaces.com/Finding+the+Right+Tool