Standardizing Documentation for Postoperative Nausea and Vomiting in the Electronic Health Record

Abstract

Postoperative nausea and vomiting (PONV) remains a common postoperative complication that causes patient discomfort and increases health care costs. Clinicians use the American Society of PeriAnesthesia Nurses (ASPAN) guideline to help prevent and treat PONV. However, the lack of standardized terminology in the electronic health record (EHR) and the lack of clinical decision support tools make it difficult for clinicians to document guideline implementation and to determine the effects of nursing care on PONV. To address this, we created a concept map of the Perioperative Nursing Data Set (PNDS) that illustrates the relationship between elements of this standardized nursing terminology and the ASPAN guideline, using the Systematized Nomenclature of Medicine-Clinical Terms multidisciplinary terminology to fill any gaps. This mapping results in a standardized dataset specific to PONV for use in an EHR, which links nursing care to nursing diagnoses, interventions, and outcomes. The mapping and documentation in the EHR also allows standardized data collection for research, evaluation, and benchmarking, which makes perioperative nursing care of patients who are at risk for or experiencing PONV measureable and visible. Distributing this information to perioperative and perianesthesia nursing personnel, in addition to implementing risk assessment tools for PONV and clinical support alerts in electronic documentation systems, will help support implementation of the PONV clinical practice guideline in the EHR.

Gender-Specific Differences in Low-Dose Haloperidol Response for Prevention of Postoperative Nausea and Vomiting: A Register-Based Cohort Study

“…Besides the study design, the suspected incomplete documentation of smoking status and history of PONV might be considered as a problem. Compared with community prevalence of smoking status or PONV history our values seem to be too low for both parameters [ 6 , 42 , 43 ]. However, the imprecise documentation should not lead to systematic bias of effect estimates of any variable since the missing mechanism for smoking status and history of PONV should be completely at random.…”

Patients’ self‐reported nausea: Validation of the Numerical Rating Scale and of a daily summary of repeated Numerical Rating Scale scores

“…Fast-track programmes and day surgery have developed rapidly (Prabhakar, Cefalu, Rowe, Kaye, & Urman, 2017), highlighting the importance of an active approach before these patients return home. To detect patients with nausea, the use of patients' self-rated scores is recommended (Apfelbaum et al, 2013;DeBlieck et al, 2013). Frequent assessments of nausea are an important strategy to invite patients to participate in care.…”

“…To facilitate patients' recovery, that is, to relieve nausea-associated discomfort and medical risks, the use of patient-reported NRS scores may be just as applicable when communicating postoperative nausea as for pain. Furthermore, to meet the demand for documentation of symptom trajectories (DeBlieck et al, 2013;Gerbershagen et al, 2013;Saranto & Kinnunen, 2009), a daily summary of patients self-reported postoperative pain at rest and during activity were shown to be valid when assessments were frequent (Wikström et al, 2017). These results suggest that daily summaries of patients' self-reported postoperative nausea with the NRS are useful for evaluating postoperative nausea.…”

“…This means that health care professionals need to pay attention to postoperative nausea (i.e., measure it using validated tools) in the post anaesthetic care unit as well on surgical wards (Van Der Wees et al, 2014). Nausea, like pain, is a subjective symptom (Armstrong, 2003), which means that similar to pain, assessment of nausea intensity should ideally be based on documentable patient-reported measures (DeBlieck, LaFlamme, Rivard, & Monsen, 2013;Van Der Wees et al, 2014). Despite insufficient literature on whether routine nausea assessments are associated with fewer postoperative complications, the American Society of Anesthesiology conclude that monitoring of nausea visualises patients' suffering and thereby facilitates individualised treatment, which in turn could contribute to reduction of PONV-related risks for complications (Apfelbaum et al, 2013).…”

“…However, like pain, nausea has consequences for the patients' ability to recover postoperatively regardless of when it occurs during the postoperative period (Allvin et al, 2008). In assessments of postoperative pain, patients are asked to rate their pain with onedimensional pain scales, such as the Numeric Rating Scale (NRS; Hjermstad et al, 2011); however, the use of scales seems to be limited in assessments of nausea (DeBlieck et al, 2013) and is not included in nurses' procedures for managing patients nausea (Börjeson et al, 2010). The Visual Analog Scale (VAS) with the endpoints no nausea and worst possible nausea has been validated and described by patients as easy to use (Boogaerts, Vanacker, Seidel, Albert, & Bardiau, 2000;Meek, Kelly, & Hu, 2009).…”