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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.



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


An observational pre/post standardization design was used.


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.


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.


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


history of present illness; informatics; preoperative evaluation; standardization

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