Quality Improvement in Documentation of Postoperative Care Nursing Using Computer-Based Medical Records

Postanesthesia nursing should be documented with high quality. The purpose of this retrospective case–based study on 49 patients was to analyze the quality of postoperative documentation in the two existing templates and, based on this audit, to suggest a new template for documentation. The audit on the template with quantitative data showed satisfactory documentation of postoperative care nursing in 67% (18% to 92%; mean [min-max]) of the scores. The template for documentation using qualitative descriptions was used by 63% of the nurses, but the keywords were used to a varying degree, that is, from 0% to 63% of records. The analysis also revealed noncompliance with clinical guidelines and multiple duplicate entries. Based on this audit, a new template was constructed, with 10 physiological parameters and drop-down lists with keywords within each parameter. In this way, implicit knowledge could be converted to explicit documentation. Furthermore, the quality of documentation was improved.