An Evidence-based Preoperative Evaluation Documentation Template Improves Perioperative Communication

Abstract

Objectives The number of surgeries performed in the United States has increased over the past two decades, with a shift to the ambulatory setting. Perioperative complications and mortality pose significant health care burdens. Inadequate preoperative assessment and documentation contribute to communication failure and poor patient outcomes. The aim of this quality improvement project was to design and implement a preoperative evaluation documentation template that not only improved communication during the perioperative pathway but also enhanced the overall user experience.

Methods We implemented a revamped evidence-based documentation template in the electronic medical records of a health care organization across three internal medicine clinics on the downtown campus and seven satellite family medicine clinics. A pre- and postintervention design was used to assess the template utilization rate and clinician satisfaction.

Results The preoperative template utilization rate increased from 51.2% at baseline to 66.5% after the revamped template “went live” (p < 0.001). Clinician satisfaction with the preoperative documentation template also significantly increased (30.6 vs. 80.0%, p < 0.001).

Conclusion Adopting a user-friendly, evidence-based documentation template can enhance the standardization of preoperative evaluation documentation and reduce the documentation burden.

Keywords

encounter notes - documentation burden - provider–provider communications - workflow and human interactions - user acceptance and resistance - process improvement

Authors' Contributions

X.P. designed the overall QI project with significant guidance, supervision, and oversight from B.H.I., S.A.S., and D.P., X.P. provided analyses of the data and interpretation of the project result. X.P. wrote the manuscript with input B.H.I., S.A.S., and D.P. All authors read, reviewed, and contributed critical revisions to the manuscript. All authors gave final approval of the version of the article to be published.

Protection of Human and Animal Subjects

This QI project was granted Institutional Review Board (IRB) exemption after its review for human subject protection by the University of Minnesota School of Nursing IRB. Human subjects were not included in the project.

Data Availability

The data underlying this article will be shared on reasonable request to the corresponding author.

Publication History

Received: 03 September 2023

Accepted: 19 December 2023

Article published online:
14 February 2024

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