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Does Perioperative Documentation Transfer Reliably?

Ridout, Jamie MSN, RN, NEA-BC, CNOR; Aucoin, Julia DNS, RN-BC, CNE; Browning, Anne RN; Piedra, Katerina RN, CPAN; Weeks, Sheila RN, CPAN

CIN: Computers, Informatics, Nursing: January 2014 - Volume 32 - Issue 1 - p 37–42
doi: 10.1097/CIN.0000000000000017
Feature Article

In the complex and multiphasic perioperative process, there are many opportunities to transfer information between providers and settings. Previous studies have shown that information transfer and communication are vital to minimize risks in the perioperative setting. The aim of this study was to explore the incidence of failure to communicate vital information as the patient progressed through the six phases of the perioperative process. The systematic sample included ambulatory surgery patient records from one quarter. A failure to communicate rate was calculated as 10.2% for the 5586 entries. In the absence of a comprehensive electronic health record, a consistent method for information transfer must be used to minimize risks.

Author Affiliations: Duke University Health System (Ms Ridout) and Duke University Health System (Dr Aucoin, Mss Browning, Piedra, and Weeks), Durham, North Carolina.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

Corresponding author: Jamie Ridout, MSN, RN, NEA-BC, CNOR, Duke University Health System, Durham, NC, 3100 Tower Blvd, Suite 600, Box 3229, Durham, NC 27710 ( Jamie.ridout@duke.edu).

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.