Documentation of Vital Signs During the Post-Operative Phase

Post-Anesthesia Care Units (PACUs) were introduced in the 1930s to address excessive post-operative morbidity and mortality rates. The PACU provides an area where patients recovering from anesthesia can be observed intensely and treated appropriately until they return to a stable physiological state. Measurement of vital signs has always been a central task of the nurses providing care in the PACU; abnormal vital signs indicate an unstable patient and the possibility of an adverse event. Over time, both hospital policies on conduct of care in the PACU, including documentation of vital signs, and the technology for measuring vital signs have evolved. Measurement of vital signs has been automated, with indicators measured either continuously or at timed intervals. This automation may produce unintended consequences including conflicts between the technology and policy and the tendency for nurses to document vital signs as a matter of routine rather than a means of delivering patient-centered care. This retrospective chart review was conducted to identify the prevalence of non-compliance with hospital policy on frequency of vital sign documentation in adult ASA I and II patients of any gender undergoing general anesthesia for an outpatient procedure. The results of this study showed non-compliance occurred in 18% of the sampled records. Recognizing such gaps in vital sign documentation, will better enable the Advanced Practice Nurse (APN) to facilitate effective discussions about the benefits of appropriate documentation and patient care. The APN can support nurses and their organization by advocating for continued involvement in policy development and staff education