amO m

Jab m, , I r m m- i n~s
I Ll LI B ~11 I b . ~
A Gui de to Revi si ng
the Post anest hesi a Care
Uni t Document at i on Record
SOPHIE RYBAK, RN
PAM BUSH, BScN, RN
The envi ronment of the PACU is changing rapidly, as are the standards,
protocols, and requi rement s of document at i on. Nursi ng care activities mus t
be capt ured in a timely, accurate, and ef f i ci ent manner t hat reflects the
st andards of care and qual i t y practice, whi l e reduci ng the amount of act ual
writing required. Thi s article revi ews the available literature and def i nes a
process to gui de one through the revision of a document at i on record.
9 1999 by Amer i can Society of Peri Anest hesi a Nurses.
T
HE STAFF of a progressive PACU in a
700-bed tertiary care Canadian academic
health sciences center recognized that the documen-
tation record had not kept pace with their profes-
sional nursing practice. The unit staff had a strong
quality i mprovement philosophy. 1 The shift to
unit-based continuous quality i mprovement 2 and
the implementation of unit councils resulted in the
devel opment of new standards of care and the unit
staff taking a more active role in the change
process. The purpose of this article is to outline the
process used to develop a documentation record
that supports professional nursing practice and
adheres to legislative requirements. In Ontario,
provincial legislative requirements dictate that each
hospital must adopt a workload measurement tool
to accurately reflect the actual patient care hours
used by the hospital. This documentation record
facilitated capturing the nursing workload data.
The PACU is a 20-bed unit, providing care to a
wide variety of surgical specialities, excluding
pediatrics, cardiac surgery, and outpatients. The
average census is 650 patients per month, with
lengths of stay varying from 30 minutes to 48
hours. The unit also functions as the critical care
overflow area when the intensive care unit is full.
The PACU is staffed 24 hours a day, 7 days a week,
solely by professional registered nurses. The nurs-
ing staff recognized that the documentation record
was no longer meeting the needs of the quality-
focused unit, which operated within a professional
nursing practice model. The document was a 1-page
record with the intraoperative anesthesia record on
the reverse side. The PACU nursing staff wanted a
more user-friendly, all-inclusive document that
reflected the unit standards of care and quality
practice, while reducing the amount of actual
writing required.
As part of the quality i mprovement process, the
documentation was reviewed, and many inconsis-
tencies were found in the charting methods. Stan-
dard abbreviations and definitions were not used,
Sophie Rybak, RN, is a Clinical Nurse and Pam Bush, BScN,
RN, is Clinical Services Manager at The Ottawa Hospital, Civic
Campus, Post Anaesthesia Care Unit, Ottawa, Ontario, Canada.
Address correspondence to Sophie Rybak, RN, The Ottawa
Hospital, Civic Campus, Post Anaesthesia Care Unit, 1053
Carling Ave, Ottawa, Ontario, Canada, KIY 4E9.
9 1999 by American Society of PeriAnesthesia Nurses.
1089-9472/99/1405-0002503.00/0
Journal of PeriAnesthesia Nursing, Vo114, No 5 (October), 1999: pp 251-259 251
252 RYBAK AND BUSH
resulting in a variety of interpretations of what was
being documented. For example, pain was charted
in the graphics portion of the old record, and one
mi ght find a checkmark to indicate the presence of
pain or a " 0" to indicate the absence of pain. This
did not allow an objective description of the pai n
intensity that is necessary for the assessment of
pain and determination of analgesia effect. 3 An-
other exampl e was charting continuous bladder
irrigation after transurethral resection of the pros-
tate gland; a checkmark indicated that the proce-
dure was performed but did not give a description
of the return. Unusual bleeding or clotting was
laboriously documented in the nurses' notes.
Uni t staff also recognized that a change in the
patient care delivery syst em would i mpact the
documentation requirements. Primary nursing was
being i mpl ement ed in the PACU as the model of
patient care delivery to ensure that each patient
admitted to the unit was assigned to a pri mary
nurse during the tenure of their stay. The pri mary
nurse, in collaboration with the patient, family, and
other health care t eam members, was responsible
for planning, coordinating, and evaluating the Care
received by the patient. The identification of the
pri mary nurse had to be incorporated into the
documentation record.
The PACU staff recognized the need to develop a
progressive, "al l -i ncl usi ve" documentation record
that accurately reflected the professional practice
and standards of care. A small commi t t ee of 3
nurses was formed tO facilitate the revision and the
i mpl ement at i on process. The first step was to
revi ew the literature for articles that would guide
the commi t t ee through the process.
LITERATURE REVIEW
In revi ewi ng the literature, a number of articles
were found related to critical care and PACU
documentation, but the flow sheets presented in the
literature did not meet the identified needs of the
unit. There was no direction/process outlined to
guide the unit through the revision. Therefore, a
decision was made to devel op a process that mi ght
serve as a guideline to others.
I yer 4 briefly outlined a number of legal issues in
relation to documentation, emphasizing the impor-
tance of using authorized abbreviations and chart-
ing promptly. Voigt et al3 stressed the importance of
standardized documentation of pain assessment.
The use or addition of a pain scale was recom-
mended to i mprove the assessment of pain and the
evaluation of analgesia. Groethe 5 recommended
flow charting to reduce documentation t i me and
identified the need for utilization of definitions. The
literature provided useful information: however, it
did not give direction to initiate the revision
process.
Cooperat i on and i nvol vement from all members
of the PACU t eam were essential to successfully
develop and i mpl ement a new documentation rec-
ord. This was confirmed by Allan, 6 who stressed the
importance of involving nurses in the change
process and their need to critically evaluate their
nursing practice. The PACU nurses were increas-
ingly involved in participative decision-making
related to patient care, nursing practice, and other
professional issues. There was strong support for
revising the documentation record, because it was
evident that the current record no longer met the
needs of the unit, but it became clear that this
would be a long and involved process.
INFORMATION GATHERING
After the literature review, the next task of the
commi t t ee was to gather information. More than
hal f of the 18 teaching hospitals of comparabl e size
across Canada who were contacted provided copies
of their PACU documentation records. The records
ranged in length f r om 1 to 4 pages. Most records
were a combi nat i on of flow charts and narrative
notes. Many incorporated a postanesthetic recovery
score into their record. Mi ni mal use of definitions
to encourage standardization of documentation was
found. This information was shared with all the
other PACU nurses, and feedback was solicited
from t hem to determine which features of the peer
records as well as any other characteristics they
wished to incorporate into the new record.
Over the course of the revision, a formal process
evol ved (Table 1). This process was used to guide
the committee. Commi t t ee members assisted the
staff to devel op and prioritize objectives emphasi z-
ing the internal and external variables affecting the
documentation record. Objectives were established
to devel op a flow sheet that not only collected
clinical data, but also was supportive of the quality
i mpr ovement activities, professional nursing prac-
tice model, and legislative changes.
The PACU staff was actively involved in the
Ontario Post Anaesthetic Nurses Association and
felt strongly that the Standards of Post Anaesthesia
REVI SI NG THE PACU DOCUMENTATI ON RECORD 253
T a b l e 1. P r o c e s s f o r R e v i s i n g a D o c u m e n t a t i o n R e c o r d
1. Establish a smal l , uni t-based commi t t ee.
2. Devel op a critical path wi t h real i sti c t i me frames.
3. Revi ew t he avai l abl e l i terature and gat her i nf or mat i on
f r om peer hospi tal s.
4. Det ermi ne obj ecti ves an d s e t p r i o r i t i e s f or t he r e v i s i o n ,
keepi ng in mi nd any internal and ext ernal f act ors t hat
may i mPact on t he record.
5. Det ermi ne a met hod of communi cat i ng i nf or mat i on
and gatheri ng i nput f r om Unit st af f and t he Depart ment
of A n e s t h e s i o l o g y .
6. Draft several potent!al document at i on r e c o r d s f o r
r e v i e w by Staff.
7. Submi t fi nal draf t f or pri nti ng.
8. Fol l ow your hospi ta! pol i cy regardi ng submi ssi on t o
t he Forms Commi t t ee f or approval .
9. Devel op audi t t ool s t o det ermi ne whet her t he docu-
ment at i on record met t he obj ecti ves i denti fi ed in step 4.
10. Educate t he PACU and surgical nursi ng uni t staff.
11. Pi l ot t he new record.
12. Eval uate t he record using audi t t ool s, and revise as
necessary.
Nursing Practice 7 must be adhered to and be
evident in their documentation. The commi t t ee
therefore had to be cognizant of these standards
during the revision process.
The PACU had a very active Continuous quality
i mprovement committee, which revi ewed and de-
vel oped standards of care for the unit. The continu-
ous quality i mprovement commi t t ee had recently
devel oped standards for pulse oxi met ry monitor-
ing, temperature monitoring, and bl ood pressure by
auscultation. This commi t t ee requested that the
documentation record reflect these newly d e v e l -
oped standards.
The documentation commi t t ee was delineating
the objectives, whi l e pri mary nursing was being
introduced into the PACU. This patient care deliv-
ery syst em assigns a primary nurse to develop a
pl an of care for the patient from admission to the
PACU until the t i me of discharge. I t was the goal of
the unit-based pri mary nursing commi t t ee to ensure
that the key principles of pri mary nursing 8 were
met in the documentation record. The pri mary
nursing commi t t ee wanted to facilitate communi ca-
tion and accountability. Space was included on the
record to indicate the pri mary and associate nurses
for the patient. A section was provi ded for the
pri mary nurse to d.evelop a care pl an as needed.
Included in the graphic porti0n of the documenta-
tion record was an area for the nursing staff to
initial to indicate the giving and receiving of verbal
reports.
It was anticipated that the pending i mpl ement a-
tion of the workl oad measurement tool would have
an i mpact on the record. In vi ew of this, the
revision of the documentation record was put on
hold. After the i mpl ement at i on of the workl oad
measurement tool, a number of patient care activi-
ties were identified that were routinely performed
but not documented on the old record. Some
exampl es were mouth care. repositioning, reappli-
cation of warm blankets, and reporting activity
between nurses. The commi t t ee wanted to incorpo-
rate all of these activities into the new record.
The PACU nursing staff t ook this opportunity
to examine current discharge practices in other
PACUs. The discharge criteria and scoring that
were in use were reviewed, and it was determined
that they did not meet the needs of the unit. The
typical discharge scoring syst em included a subjec-
tive assessment of color but did not include oxygen
saturation, temperature, pain, nausea, and vomi t -
ing. The nursing staff wanted more progressive
discharge criteria that reflected the standards of
care provided. After consultation with the Medical
Director of the PACU, an objective recovery score
and discharge criteria were developed. The new
recovery score included an assessment of oxygen
saturation rather than color. Temperature was in-
cluded to emphasi ze the i mport ance of normother-
mi a on patient recovery. A standardized assessment
of pai n using a verbal numerical score was in-
cluded, as well as a scoring syst em for nausea/
vomiting. This recovery score is included in the
graphic portion of the documentation record.
With the workload measurement syst em and
pri mary nursing well under way, the commi t t ee
resumed the task of revising and drafting the PACU
record. A series of drafts were devel oped and
shared with the PACU t eam and the Depart ment of
Anaesthesia. Feedback was obtained and revisions
made. The resulting 4-page record (Fig 1) was then
sent to the Depart ment of Reprographics for type-
setting and laser printing. At this point, it was easy
to move segments to facilitate the flow of the
document and to make changes suggested by the
printer. The final draft was again shared with the
Department of Anaesthesia and the Director of
Nursing for their input. The new documentation
record was then submitted to the Hospital Forms
Commi t t ee for revi ew and approval.
254 RYBAK AND BUSH
OTTAWA CiViC HOSPITAL
POST ANAESTHESIA CARE UNIT RECORD
Date:
Procedure:
Reporting Anaesthetist:
Primary Nurse:
Associate Nurse(s):
Time: From:
IntitaL
Initial:
Position of Patient:
[ ] Left lateral [ ] Right lateral [ ] Supine
Type of Anaesthetic:
[ ] General [ ] Spinal [ ] Epidural [ ] Local
D Other
Airway:
[ ] None [ ] Endotracheal [ ] Nasotracheal
[ ] Oralpharyngeal [ ] Nasopharyngeal
Removed @ __. hour s Removed by
Oxygen:
[ ] None required [ ] Mask [ ] Nasal Prongs
[ ] Ven!imask [ ] Non-Rebreathing Mask
02 @ 1/min Fi02 @ %
Ventilator Assist:
ventilator type [ ] SIMV
Rate /min Fi02 % TV__
[ ] Semi Fowlers [] HOB @ degrees
[ ] Regional [ ] IV Conscious Sedation
[ ] Laryngeal Mask [ ] Trachenstomy
[ ] T-piece [ ] Trach Hood
[ ] Assist/Control O CPAP
PEEP PS__
Equipment:
[ ] Pulse Oximeter
[ ] EKG Monitor; Rhythm
CI Arterial line [ ] ft. side Cl it. side
[ ] CVP line [ ] rt, side [ ] It, side
[ ] PA catheter [ ] rt. side [ ] It. side
[ ] Epidural; site
[ ] CPM @ degrees
[ ] Traction; site
[ ] Forced Air Warming System
[ ] Other
Surgica! Site:
#1 Location Type Condition
#2 Location Type Condition
[ ] Peripad drainage
Drains, etc.:
[ ] Hemovac x , site [ ] Foley catheter; drainage _ _ [ ] NG tube to
[ ] Jackson Pratt x . site [ ] Suprapubic catheter; [ ] Irrigations; type
[ ] Penrose; site drainage Return
[ ] Chest tube x @ cm H20 suction [ ] Ileoconduit; drainage _ _ [ ] Cast; condition
[ ] Fluctuation [ ] Bubbling [ ] Nephrostomy: [ ] rt. [ ] It, [ ] Packing; site
[ ] Colostomy/Ileostomy stoma drainage _ _ [ ] Other:
suction
Comments on Admission:
Primary Nursing Plan of Care:
[ ] I.D, Check (x4)
Signature of Admitting Nurse RN
[ ] Dr. Orders Checked (x2)
Fig 1. Ottawa Civic Hospital Post Anaesthesia Care Unit Record. Reprinted with permission from the Civic Campus of the Ottawa
Hospital, Ottawa, Ontario, Canada.
REVI SI NG THE PACU DOCUMENTATI ON RECORD 255
RECOVERY SCORE:
Level of Consciousness: 02 Saturation: Respiration:
2 Awake 2 Sp02>- 92% on room air 2 Able to deep breath & cough
1 Drowsy 1 Sp02-> 92% on oxygen 1 Limited breathing
0 Unconscious 0 Sp02 < 92% on oxygen 0 Requires airway support
Circulation: Temperature: Nausea & Vomiting:
2 BP+ 20%otpre-op 2 _>360C 2 Controlled
1 BP + >20% ~ 40% of pre-op t -> 34 5 C < 30 C 1 Further treatment required
0 BP+ >40%otpre-op 0 < 34.5C g Uncontrolled
Pain:
2 Controlled 1 Further treatment required 0 Uncontrolled
Level of Consciousness
Circulation
Respiration
02 Saturation
Temperature
Nausea & Vomiting
Pain
Total Score
Blood 220
Pressure 210
20O
190
v
(cuff) too
^ 170
160
150
v
I 140
(monitor) I 130
I 120
A 110
100
Pulse 9 90
80
70
6O
50
40
30
Resp. Rate
Oxygen
02 Sat %
Temp
Warm Blankets
DB&C
Pain Scale
Nausea / Vomiting
Mouth Care
Surgical Site
Peripad
Irrigations
Turn / Position
Sensory Block
Motor Block
Pulse rt
Pulse R.
Verbal Response
Pupils
Arm Stmnglh
Leg Btrenglh
Reassured
Report Given
Report Received
Initials
' ' ~! PRE-OP:
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I l f l l
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Fi g 1 ( cont ' d) . Ot t awa Ci vi c Hospi t al Post Anaest hesi a Car e Uni t Recor d. Repr i nt ed wi t h per mi ssi on f r om t he Ci vi c Campus of t he
Ot t awa Hospi t al , Ot t awa, Ont ar i o, Canada.
256
Time Medication Dose Route Signature / Initial
RYBAK AND BUSH
Allergies: [ ] NKDA
Medication Time
Dose
Init
Medication Time
Dose
Inil
[ ] IV/Epidural PCA
[ ] Dressing at site changed. Initials
[ ] EKG @ _ _ hours
RN
Medication Time
Dose
Init
started at hours. Please see PCA Medication Administration Record.
[ ] Epidural checked as per protocol. Initials RN
[ ] X-ray: type: @ _ _ hours
Volume Time Down/ Volume
Time Up Solution Additive TBA Site to Ward Infused Time Source(s) Volume
Total Intake (mls) Total Output (mls)
Time FiO2 13H pOO~ p02 HC03 B.E O~Sat Vf Rate PEEP PS RR Time WBC Hgb Hc~ PIt INR PTT
L
Time Na K CI Glu Ur Cr Ca CPK lime
Date: Time: To:
Comments on Discharge:
Discharged by: RN Patient left unit al hours
Fig 1 (cont'd). Ot t awa Civic Hospital Post Anaesthesia Care Uni t Record. Reprinted wi th permission from the Civic Campus of the
Ot t awa Hospital, Ottawa, Ontario, Canada.
REVISING THE PACU DOCUMENTATION RECORD 257
LEEr - , no.
Oerl
Motor Block Scale:
O. None - moves knees, feet and hips.
1. Partial - able to bend knees.
2. Complete - does not move leel or knees
Surgical Site:
D Dry
So Scantamounl
Sm Small amount
M Moderate amount
LG Large amount
PainS c ale:
0-3 Miid Pain
3-7 Mode~le
7-10 Sovem
Puripad:
D Dr/
S Scanl amount (< 1 inch stain)
L Light amount (>1, <4 inch stain)
M Moderate amount (>4, <6 inch stain)
H Heavy amount (saturated pad within an hour)
Bladder Irrigation:
0 Prompt & clear, or pink to clear
1 Prompt & pink with occasional clef
2 Prompt & red, with or wdhout clots
3 Sluggish
Patient Position:
S Sup(he
R Right side dovm
L Letl side down
T Trendelenburg
FIT Reverse Tmndelenburg
Miscellaneous:
R Right
L Left
N see Nurses Notes
Peripheral pulses:
0 Absent
1 FainVweak
2 Normal
3 Bounding
O by Doppler
IV Site:
FA Forearm
AC AnleuubilaI
H H~qd
W Wrist
UA Upper Arm
LA Lower Arm
Neurological Assacsment:
Pupil Reaction:
B Brisk
S Sluggish
F Fixed
C Eyes swollen shut
Limb Movement:
S Strong
E Equal
MW Mild weakness
SW Severe weakness
Veal)a1 Response:
5 Oriented
4 Confused
3 thnappropriate Words
2 Inc0roprehenslve Sounds
1 None
Fig 1 (cont' d). Ot t awa Civic Hospi tal Post Anaest hesi a Care Uni t Record. Repri nt ed wi t h permi ssi on f rom t he Civic Campus of t he
Ot t awa Hospi tal , Ot t awa, Ontari o, Canada.
258 RYBAK AND BUSH
EDUCATION, PILOT, AND FEEDBACK
Once the draft documentation record was re-
ceived from Reprographics, guidelines were devel-
oped to facilitate the completion of the new docu-
ment at i on record. The commi t t ee member s
undert ook one-on-one education of the 28 PACU
staff nurses to revi ew the rationale and principles
behind the new documentation record, as well as
proper documentation procedures. This process
t ook approxi mat el y 1 mont h to complete.
An implementation date was set to distribute the
new record and begin its use. This information was
communi cat ed through memos to all nursing units
before implementation. The clinical nurse educa-
tors assigned to the surgical nursing units assumed
responsibility for i nformi ng their staff about the
record and its interpretation. A pilot of 3 to 4
mo n t h s was planned for the PACU nurses to
become familiar and comfort abl e with the new
record. This would also allow enough time to
determine any necessary i mprovement s or dele-
tions that would be required to the pilot record
before the anticipated final printing.
During the pilot phase, a binder was provided for
PACU staff and anesthesia staff to communi cat e
any comment s, concerns, constructive criticisms,
and suggestions for i mprovement , with the intent to
revi ew these at the end of the pilot phase. The
comment s were taken into consideration while
revising the documentation record.
EVALUATION
To evaluate the nursing practice and standards,
audit tools were developed. For example, the
standard for monitoring of blood pressures by
auscultation was audited with both the old and new
records. The revised standard of care for blood
pressure monitoring requires combination bl ood
pressures by auscultation and palpation rather than
the past practice of bl ood pressure by palpation
only. An increase in compliance by 20% was found
with the new record.
The provision of definitions on the documenta-
tion record has helped ensure consistency in docu-
mentation practices. For example, a verbal pain
scale has been incorporated into the graphic portion
of the new record to standardize pain assessment. A
definition has also been devel oped to describe the
return of irrigation fluid by using a simple code that
is charted under Irrigations in the graphic section of
the new record, using the codes provided in the
legend under Bladder Irrigations. This has reduced
documentation t i me and i mproved consistency in
charting. The audit process has confirmed these
findings.
The PACU Pri mary Nursing Commi t t ee devel-
oped an audit tool to moni t or continuity of care
based on the new documentation record. This audit
is in progress, and it appears that the revised record
supports continuity of care, specifically through the
use of the care plan. Some exampl es of what might
be included in the care plan include special needs of
the patient (ie, positioning, prosthetic devices,
language interpretation needs, specific cultural
needs) and the actual plan of care for the patient.
The new documentation record more accurately
reflects the care being provided. This has been
confirmed by an increase in the patient care hours
identified in the workload measurement system
after implementation of the new documentation
record. Finally, the charting t i me has been reduced
by decreasing the amount of handwritten informa-
tion and replacing it with standardized, objective
flow charting, while meeting legal requirements.
SUMMARY
The revision of the documentation record has
provided the commi t t ee with an opportunity to
learn about the change process and the challenge of
working with large groups. Over the course of the
revision, a formal process evol ved (Table 1), which
was used to guide the committee. The process that
was followed has resulted in a progressive modern
documentation record unlike any of those provided
by peer hospitals or published in the literature.
As a professional staff i nvol ved in decision
maki ng and seeking accountability and autonomy,
there was no question that the PACU t eam had to
participate in the revision process. The PACU
nurses identified the need for a progressive docu-
mentation record that accurately reflected the high-
quality care provi ded in the PACU. The commi t t ee
facilitated the devel opment and implementation of
the revision.
The aspects of the process that were particularly
important were the determination and setting of
priorities for the revision, keeping in mind any
internal and external factors that i mpact on the
record. Ensuring open communi cat i on among the
PACU and Depart ment of Anaesthesia staff fos-
R E VI S I NG T HE P ACU DOC UME NT AT I ON R E C OR D 259
t e r e d pa r t i c i pa t i on i n t he pr oc e s s a nd a c c e p t a n c e o f
t he f i nal pr oduct .
I n r et r os pect , t hi s pr oc e s s wo u l d h a v e b e e n
f a c i l i t a t e d by h a v i n g a s l i ght l y l a r ge r c o mmi t t e e o f
4 t o 5 me mb e r s t o ga t he r and d i s s e mi n a t e i n f o r ma -
t i on t o t he staff. A cr i t i cal pat h wi t h de f i ne d t i me
f r a me s and a r e s pons i bl e pe r s on i de nt i f i e d wo u l d
h a v e p r o v i d e d a t ar get a nd ma y h a v e h e l p e d t o ke e p
t he pr oj e c t f oc us e d. Ke e p i n mi n d t hat a ma j o r
r e v i s i o n o f a d o c u me n t a t i o n r e c o r d c a n be a 1- t o
2- ye a r pr oc e s s a nd t hat s o me obs t a c l e s ma y be
e n c o u n t e r e d a l ong t he way. On e o f t he gr e a t e s t
obs t a c l e s wa s c o mi n g t o c o n s e n s u s o n wh a t s houl d
b e i n c l u d e d or e x c l u d e d f r o m t he r ecor d.
ACKNOWLEDGMENT
The authors thank Dr Jo Logan, PhD, RN, Assistant Profes-
sor, Faculty of Health Sciences, University of Ottawa, and
Kathleen Graham, MN, RN, Clinical Director, Surgical Portfo-
lio, the Ottawa Hospital, Civic Campus, for their encourage-
ment, support, and valuable expertise in the development of this
article. The development of the documentation record would not
have been possible without the enthusiasm, expertise, and
participation of the clinical nursing staff in the PACU of the
Ottawa Hospital, Civic Campus.
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