Perioperative Documentation in Finland

AORN Journal, Nov, 2000 by K. Junttila, S. Salantera, M. Hupli

The aim of perioperative documentation is to collect and record information to support and justify care provided to a surgical patient and to document a patient's responses to that care. In Finland, research studies about perioperative documentation are few. In addition, Finland does not have professional recommendations for perioperative documentation, such as AORN's Standards, Recommended Practices, and Guidelines.(1)

To clarify current practice in Finland, its potential problems and strengths, and, thus, develop a standard for perioperative documentation, the University of Turku, Department of Nursing Science, Turku, Finland, undertook a study. The study explored current practices and contents of perioperative documentation in Finland and clarified how satisfied health care workers were with their particular perioperative documentation.

PATIENT RECORDS IN FINLAND

In Finland, there are several laws and regulations that relate to patient records. For example, the Act on the Status and Rights of Patients defines patient records as all material related to a patient's care (ie, information related to patient examinations, care, or counselling).(2) This material can consist of a patient's health or other personal information. The same act gives the Ministry of Social Affairs and Health authority to draft and maintain patient records.

The Finnish Act Concerning Health Care Professionals says that one responsibility of health care workers is to create and maintain patient records according to regulations. It also notes that these workers are bound to secrecy under any circumstances.(3) The Personal Data Act details regulations concerning the use of such delicate information as a patient's race; ethnic, political, or religious background; and sexual behavior.(4) Finally, the Regulation on Drafting and Keeping Patient Documents provides concrete advice about such practices as when and how to create patient records and how to make alterations.(5)

In Finland, the surgical team generally comprises the surgeon(s), an anesthesiologist, a nurse trained in anesthesiology, and two perioperative nurses (ie, scrub person, circulating nurse). The surgeon must produce a surgical report for each procedure. All anesthesia activities are documented on the anesthesia record. The postanesthesia care unit usually has its own form, or the postoperative charting can be documented on the anesthesia record. All these documents are included in the patient's record. In addition, perioperative nurses may use a specific perioperative form for their notes about patient positioning, instrument counting, and disinfection of the surgical area. The structure and content of perioperative documentation forms vary within surgical departments.

Nursing documentation can act as legal evidence and should reveal nursing decisions, interventions taken during patient care, and why, when, and by whom these decisions and interventions were made. In addition, documentation should reveal what effect interventions had on a patient's health, welfare, behavior, and coping.(6) Perioperative nursing documentation also provides a patient with accurate information relating to his or her care. Nurses have a professional obligation to record that care. Documentation emphasizes nurses' commitment to making their practice visible and understandable by revealing the decision-making process during a patient's care and the outcomes of that process.

LITERATURE REVIEW

The theoretical basis for nursing documentation is built on decision making, including a series of decisions, such as

* decisions regarding what to observe and what data are more relevant in a particular patient situation;

* inferential decisions (ie, deriving meaning from the data observed); and

* decisions regarding what actions should be taken to achieve desired patient outcomes.(7)

In nursing, decision-making research has been guided by rational decision-making theory, information processing theory, and phenomenological theory. Of these, the first two represent the analytical thinking process, and the phenomenologic view emphasizes intuition in the decision-making process.

Decisions are influenced by several factors (eg, the knowledge base and experience of the decision maker, the context of decision making, the task to be solved, the time available for decision making). In reality, analytical and intuitive thinking support and complete each other.(8) One model of clinical expertise emphasizes the meaning of practical experience in decision making.(9) As a novice, a nurse's decision making involves separate situations, is partly nonanalytical, and is based on rules and principles. With experience, decision making becomes more holistic and flexible and includes intuition--an expert has an intuitive grasp of the whole situation. Recent studies have identified two habits of thought and action in perioperative nurses: clinical grasp and inquiry (ie, problem identification, clinical problem solving) and clinical forethought (ie, anticipating and preventing potential problems).(10)