Evidence-based Practice: Updating Contingency Paper Documentation.

Abstract

Purpose: Contingency Paper Documentation (CPD) in the postanesthesia care unit (PACU) was outdated and did not include all required documentation. Crucial assessment, education, and readiness for discharge were not.

Design: The design of this project and literature review was based on the Problem-Intervention-Comparison-Outcome question-How can CPD be improved to include all required PACU assessments, education, and discharge criteria?

Methods: Review and rating of literature for evidence was specific to nursing documentation and paper documentation. Staff provided input to update the PACU CPD document. Multiple Plan-Do-Study-Act cycles were implemented to create the final document.

Findings: There was a lack of information specific to updating the CPD. Themes identified with the literature review include the flow of documentation should mimic nursing care provided, the process, and the Electronic Health Care Record; to include user input in improvement initiatives; include evidence-based recommendations/regulations; consider quality and include outcomes in documentation; avoid abbreviations, and to use standardized language.

Conclusions: The PACU CPD was updated with staff input and evidence from the literature review, and with trialing the document for formatting and content. The updated form is quicker and easier to use, with less content written in free text. Future quality assessment of the new document is planned to include quality of documentation, legibility, and meeting organizational documentation requirements, as compared with the previous CPD.