Planning and documentation. Addressing patient needs in a day surgery setting. 1988

S M Page, and L A Beresford
Northwest Hospital, Seattle.

Day surgery has reduced the time allowed for patient contact, but it has not reduced the need for assessment, planning, and delivery of patient care. Day surgery, however, has shifted some responsibility from nurses to patients and their families. Our goals in developing a preoperative assessment plan were to ensure consistent and thorough patient assessment; enhance problem identification and guide appropriate interventions; provide evaluations based on the needs of the day surgery patient; assist patients and families in assuming increased responsibility for postoperative care; provide achievable and manageable documentation of patient information gathered in a compressed amount of time; and facilitate communication between the patient and the health care team. We feel our assessment documenting system meets these goals and allows nurses and patients to adapt to the changes in traditional roles both parties experience when day surgery procedures are performed.

UI MeSH Term Description Entries
D009737 Nursing Records Data recorded by nurses concerning the nursing care given to the patient, including judgment of the patient's progress. Records, Nursing,Nursing Record,Record, Nursing
D009871 Operating Room Nursing The functions of the professional nurse in the operating room. Nursing, Operating Room
D010347 Patient Care Planning Usually a written medical and nursing care program designed for a particular patient. Nursing Care Plans,Goals of Care,Plans, Nursing Care,Care Goal,Care Goals,Care Plan, Nursing,Care Planning, Patient,Care Plans, Nursing,Nursing Care Plan,Plan, Nursing Care,Planning, Patient Care
D004282 Documentation Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature (From ALA Glossary of Library and Information Science, 1983). It often involves authenticating or validating information. Documentations
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D000556 Ambulatory Surgical Procedures Surgery performed on an outpatient basis. It may be hospital-based or performed in an office or surgicenter. Ambulatory Surgery,Day Surgery,Office Surgery,Outpatient Surgery,Surgery, Office,Surgery, Outpatient,Ambulatory Surgical Procedure,Procedure, Ambulatory Surgical,Procedures, Ambulatory Surgical,Surgery, Ambulatory,Surgery, Day,Surgical Procedure, Ambulatory,Surgical Procedures, Ambulatory,Ambulatory Surgeries,Day Surgeries,Office Surgeries,Outpatient Surgeries,Surgeries, Ambulatory,Surgeries, Day,Surgeries, Office,Surgeries, Outpatient

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