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.
Copyright © 2017 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.