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J Perianesth Nurs. 2018 Aug;33(4):436-443. doi: 10.1016/j.jopan.2016.08.016. Epub 2017 May 13.

Compliance Is Contagious: Using Informatics Methods to Measure the Spread of a Documentation Standard From a Preoperative Clinic.

Abstract

PURPOSE:

Preoperative documentation is essential to coordinated care and has the potential for standardization, which may facilitate downstream clinical management.

DESIGN:

An observational pre/post standardization design was used.

METHODS:

We analyzed the implementation of a preoperative documentation standardization intervention in Vanderbilt's Preoperative Evaluation Clinic (VPEC) and its impact outside VPEC. A phased intervention consisted of clinician education with monthly feedback, followed by the development of a compliance dashboard and inclusion in Ongoing Professional Performance Evaluation system by VPEC. A follow-up survey was administered to measure the impact on clinical management.

FINDINGS:

Adherence to standardization was improved with the addition of electronic feedback. Implementation of this system in the preoperative clinic had significant impact outside VPEC. Trainee status was a significant predictor of adoption of the standardized format.

CONCLUSIONS:

Adoption of a preoperative documentation standard in a clinic had a positive impact on standardization practices in a perioperative system.

KEYWORDS:

history of present illness; informatics; preoperative evaluation; standardization

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