SIMPLE PNDS

Education Design by: Marisa Tapia MSN RN ACNS-BC

Hi Nancy, my name is Amelia

I am the Informatics Nurse that will guide you through this tutorialWe’ll start with what does the PNDS stand for

The PNDS stands for:

PN

DS

Perioperative

Set

Nursing

Data

Okay… but what IS the PNDS?

The PNDS reflects the perioperative clinical workflow which captures the perioperative nurse’s contributions to the patient outcomes via clinical documentation in the electronic health record

The PNDS language is a computer coded language built into the electronic record for Perioperative Nurses to capture the nurse’s documented data

In simple terms…Whatever YOU enter into the electronic health record related to patient care, will be captured using the PNDS codes within the computerized program your facility uses.

So let me get this right…..

The PNDS codes capture the documentation of the care the nurse provide in the operating room to their patients in the electronic health record.

Click to save

Am I on the right track?

The PNDS is an approved ANA (American

Nurses Association) nursing language that

provides a true perioperative standardized

method of documentation to gather data in

order to measure clinical impact versus non-

clinical variables or values such as turnover

time.

ITS IMPORTANCE

That is correct!

The PNDS includes computerized codes which will facilitate consistent electronic documentation, quality initiative identification, and clinical reporting in the perioperative setting.

Let’s Review

The PNDS is a standardized vocabulary that describes perioperative nursing practice by providing formal definitions when the nurse is documenting the care being provided to the patient in surgery.

DEFINITION

Better said:It is a standardized and controlled vocabulary that EVERY perioperative nurse uses to identify the work being done in the perioperative area when documenting or “charting” in the Electronic Healthcare Record (EHR).

I GET IT!!!!!

I GET IT!!!

A standardized single concept thatwill capture every step, skill, andcare the perioperative nurseprovides to the patient undergoingan operative or invasiveprocedure when documenting care in the ElectronicHealth Record (EHR)

YOU GOT IT!!!!

But..what’s in it for me, more work?

I already have too much to do and now this?

The PNDS will not make more work for you.

The PNDS will itemize what you do for the care you provide for each patient.

THE PNDS WILL IDENTIFY THE TRUE VALUE OF THE WORK THAT NURSES PROVIDE WHEN CARING FOR THE PATIENT IN SURGERY.

PNDS captures the essence of caring…

for the patient

The PNDS uses the nursing process as the foundation for the documentation in the electronic health record

Finally…they will

understand what I do as

a nurse in the perioperative

setting!!!

The PNDS provides the documented

value, cost-effectiveness, and

contributions of professional nurses in

the perioperative setting while gathering

reliable perioperative data for future

research related to perioperative

nursing.

The true value of what the RN does!

From admission….

…to documenting the care provided by the nurse in surgery…..

Click to save

The PNDS is a

computerized method

to collect data to

measure CLINICAL

IMPACT as well as non-

clinical

variables/values such

as turnover time

Let’s Recap:

Measuring turnover times of the room for the next case, although important at times, is not a measure of clinical nursing quality but a measure of efficiency (non-clinical processes) .

The

PNDS is…

A method to document the value, cost-effectiveness, and the contributions of professional nurses that are providing care to the patient undergoing a surgical intervention…

Isn’t that what we are supposed to be doing?

My nursing interventions

matter!

The work I do will now be captured, collected, validated and…..

My work will be studied….and

My work will provide the data for new evidence in practice

I get that the PNDS providesgreat value but….what can be gained from the PNDS?

From this To this

Additionally,The care that is documented will be collected and is retrievable via the PNDS codes for data analysis and quality measures, such as SCIP and nurse sensitive patient outcomes (NDNQI) which will establish data for best practices.

What will all this stuff generate?

HOW is it done?

The information collected

from the PNDS captures

the nurse’s interventions

which provide reliable

perioperative data for

nursing research.

Clarity, preciseness, and consistency in the

documented care given by the perioperative nurse

Perioperative practice visibility by the data being

generated reflecting the clinical work flow.

Records reliable and valid perioperative data

Allows for the comparison of the data being

captured to compare effectiveness, efficiency

PNDS codes that are built into the electronic health

record (EHR) allows you to document safe and

effective care

BUT…why use it?Here are some reasons

I am not quite sure I get it?

Based on what you document in the perioperative record the PNDS establishes and reports on: •Quality Measures •Patient-centered care•Evidence-based practice•Performance-driven outcomes

Okay, this should help:

NOW…Let’s put it all together so you can see the BIG picture of all the PNDS can do for YOU and the Patient

Basic Elements of how it is identified in the Electronic Health Record

Are You still with me?

Following you so far….

Let me give you an example

Now, how would it look like when I am documenting the nursing interventions

or the work that I do ?

But where is the PNDS?

The PNDS has built in codes In the Electronic HealthcareRecord (EHR) that you don’t See in practice but they are

there.I will show you an example

PNDS Codes are the data points that when you document will be captured and used for nursing quality outcomes

Now my nursing care will be

recognized in research studies, in evidence

based practice and in nursing quality outcomes

YOU GOT IT!

Let’s CelebrateYour Success!

You have earned 1.5 Contact Hours of Continuing Education