Standardizing Documentation for Postoperative Nausea and Vomiting in the Electronic Health Record.

  • LaFLAMME Fishman A
  • Rivard Jane M
 et al. 
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Postoperative nausea and vomiting (PONV) remains a common postoperative complication that causes patient discomfort and increases health care costs. Clinicians use the American Society of PeriAnesthesia Nurses (ASPAN) guideline to help prevent and treat PONV. However, the lack of standardized terminology in the electronic health record (EHR) and the lack of clinical decision support tools make it difficult for clinicians to document guideline implementation and to determine the effects of nursing care on PONV. To address this, we created a concept map of the Perioperative Nursing Data Set (PNDS) that illustrates the relationship between elements of this standardized nursing terminology and the ASPAN guideline, using the Systematized Nomenclature of Medicine Clinical Terms multidisciplinary terminology to fill any gaps. This mapping results in a standardized dataset specific to PONV for use in an EHR, which links nursing care to nursing diagnoses, interventions, and outcomes. The mapping and documentation in the EHR also allows standardized data collection for research, evaluation, and benchmarking, which makes perioperative nursing care of patients who are at risk for or experiencing PONV measureable and visible. Distributing this information to perioperative and perianesthesia nursing personnel, in addition to implementing risk assessment tools for PONV and clinical support alerts in electronic documentation systems, will help support implementation of the PONV clinical practice guideline in the EHR.

Author-supplied keywords

  • AORN
  • American Society of PeriAnesthesia Nurses
  • Clinical
  • Computerized Patient Record
  • Concept Mapping
  • Decision Making
  • Documentation
  • Female
  • Middle Age
  • Nausea and Vomiting -- Nursing
  • Nausea and Vomiting -- Prevention and Control
  • Nausea and Vomiting -- Risk Factors
  • Nausea and Vomiting -- Therapy
  • Nursing Classification
  • Nursing Minimum Data Set
  • Patient Centered Care
  • Perianesthesia Nursing
  • Perioperative Nursing
  • Postoperative Complications -- Nursing
  • Postoperative Complications -- Prevention and Cont
  • Postoperative Complications -- Risk Factors
  • Postoperative Complications -- Therapy
  • Practice Guidelines
  • Risk Assessment
  • Snomed

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  • Conni DeBLIECK

  • Anne LaFLAMME Fishman

  • Mary Rivard Jane

  • Karen Monsen A.

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