PNDS @ Work: Building a Perioperative Patient Record

AORN Journal, Feb, 2005 by Michele Roberts

PNDS @ Work: Building a Perioperative Patient Record Susan V.M. Kleinbeck 2004, 64 pp $15 member/$19 nonmember softcover

This book is a well-written reference that takes readers through the many phases and requirements of building a perioperative record in a manner that is similar to the nursing process itself (ie, assessing and planning through implementation and evaluation). The book emphasizes incorporating the Perioperative Nursing Data Set (PNDS), a standardized nursing vocabulary, into perioperative documentation.

Six steps for developing a perioperative patient record encourage the use of PNDS vocabulary. Step one is dedicated to using the PNDS in care plans, standards, and patient records. Step two discusses how to integrate standards of care and the PNDS into written records. Step three provides information on how to develop an electronic patient record and the collaboration needed to select vendors, hardware, and software. Steps four through six discuss staff member training and system implementation.

The author provides a broad spectrum of charting ideas and offers hints for both electronic and written documentation methods. Informational graphs and visual elements clarify difficult concepts. More than 100 hints presented in separate boxes provide simple, straight-forward information for automating the perioperative record, including helpful ideas for building computerized processes, evaluating hard-ware criteria, building clinical databases, and testing new forms. These hints are appropriate for other areas of nursing as well and could be an asset to managers in other departments who are building similar documentation systems.

I recommend that this book be added to the libraries of all health care professionals. It is small and inexpensive, and it provides a wealth of realistic and easy-to-use information for a very high-risk environment.

This book is available from AORN, 2170 S Parker Rd, Suite 300, Denver, CO 80231; http://www.aorn.org.

MICHELE ROBERTS RN, CNOR

OR MANAGER

BEARTOOTH HOSPITAL & HEALTH CENTER

RED LODGE, MONT