OR Documentation: Nurse Feedback & New Tools

Accuracy and patient safety:

In the OR, every detail matters, and accuracy in product documentation is critical.

Two data collection methods that remain popular today are manual data inputting and barcode scanning – but both have their limitations.

Manual data entry

Keying in surgical data is a slow, frustrating process that is prone to errors, such as typos, mis-read data or system errors.

Hospital systems are notoriously clunky, with a multitude of screens and dropdowns to wade through in order to record all the required details of each item.

Busy nurses often state that data entry is a frustrating task, it takes a lot time yet often fails to record all the required information. Manual keying-in is an unreliable method of surgical documentation.

A study conducted by Johnson et al. (2018) found that manual documentation errors occurred at a rate of 11.4% during surgical procedures. *1

What nurses say about keying-in data at the point of care:

• • “Incomplete information is sometimes entered making it hard to track or retrieve items.”
  • “Numbers aren’t always entered accurately, it’s a tedious process.”

In these technical times, surely, we can do better than manual data entry?

Barcode scanning

Barcode scanning is prevalent throughout the hospital and ambulatory care sectors, and of course we see it in OR and procedure rooms.

However, this method of data capture presents its own challenges. Collecting data from the item can be difficult, the barcodes placed on product packaging can be damaged or obstructed, and the sheer number of barcode labels causes delays while nurses struggle to find the one containing the information they need. Even if the barcode is successfully scanned it may not include data such as the expiry date or batch number which will then need to be manually recorded.

This method is also reliant upon the scanned item being accurately listed in the hospital’s source of truth – their Item Master. With hundreds of thousands of items listed in a healthcare organization’s Item Master, and with regular changes UDI codes and other product data, maintaining the Item Master is not a simple task.

What nurses say about barcode scanning at the point of care:

• • “Many times, items don’t scan into the database.”
  • “Some things are not captured by scanner and human errors occur when entering numbers”
  • “Sometimes we can’t find supplies (on the system) and it’s too time consuming.”
  • “Some reference numbers are not in the system, therefore have to manually enter everything in the system”
  • Documentation problems include “human error and time spent searching for items.”

So, even when barcode scanning is the system of choice – it seems that nurses end up keying-in data for many items, when the scanning process fails, or the item isn’t in the system.

Handling items not on the Item Master:

The item master, a comprehensive list of hospital inventory items, serves as the foundation for documentation. However, the Item Master may not include all the products used in surgery, especially when:

• • New items are introduced
  • Stock substitutes are delivered
  • Last-minute orders or trunk stock are used
  • Item data has been changed or updated since it was entered in the system

Nurses face the challenge of accurately documenting unlisted items, which the system simply won’t recognize. Often the added admin involved means that if items don’t find a match in the system, they end up not being documented during surgery – which puts them at high risk of not making it on to the patient file at all.

When full and accurate surgical documentation is not achieved, this can lead to inventory discrepancies, billing errors, and compromised analytics for cost containment and supply chain management.

What nurses say about Item Master issues:

• • “If the item is not found in the database many (nurses) will not search to find the correct item and so we may not be charging for the exact item used. Items are entered in the database in one way but when searching for them at the time of use the item number may have changed since the product was entered into the database.”

The fact that item documentation in surgery is so hit and miss has led many healthcare organizations to put post-surgery documentation audits in place, in an effort to rectify errors and omissions.

Nurse time and efficiency:

Nurses in the OR face immense time pressure, requiring them to balance patient care, documentation, and other responsibilities. Inefficient data capture processes and inadequate tools distract nurses from patient care.

A research study undertaken in Medical-Surgical Unit at a Mid-west academic medical center found that out of all the different tasks undertaken in a shift, nurses spent the most time charting in the EHR (31.63 mins) and reviewing information in the EHR (21.51 mins), reducing the time available for direct patient interaction. ^*2

The cumbersome process of documentation adds time and pressure onto the workload of nurses. When tools and processes are inefficient it makes the task of item documentation in surgery so much harder for busy nurses.

What nurses say about documentation time in surgery:

• • In some organizations nurses need to ensure more than one system is up to date, one nurse commented the main issue for her was that recording items, “requires duplicate charting, which is time consuming.”
  • “Whether handwritten or by keying into the computer – documentation takes too much time away from patient care.”

We can see that point of use data capture can be time-consuming, inefficient and inaccurate. If surgical documentation is incomplete or incorrect this is a risk to patient safety as the medical records will not reflect the full range of reportable items used in surgery. This vital information may be called upon in the event of an adverse reaction from a patient, or a product recall.

Data gaps pose severe patient safety risks but also lead to business inefficiencies. The data captured in surgeries and procedures ensures the smooth-running of healthcare operations, including:

• • Ensuring accurate and timely materials management
  • Optimizing medical billing
  • Ensuring robust cost management.

POU surgical data collection certainly merits review in many healthcare organizations, especially when new technology is providing an easy-to-implement and effective solution.

The need for advanced POU data capture solutions:

To address the limitations of manual data entry and barcode scanning, healthcare organizations are turning to advanced point of care data capture tools. These solutions leverage technology to automate data capture and improve accuracy. Although there are many tools on the market, there is a real difference in their usability and efficiency.

New image-recognition technology is proving to be a game changer, simplifying the task of capturing product information, including items not on the item master. But it’s not just about the data capture tool itself.

Surgical data and business analytics are needed across the organization. That’s why advanced AI cloud software that incorporates machine learning, is proving so popular. The right managing system provides seamless integration with core hospital systems, enables the real-time sharing of crucial surgical data and produces meaningful business intelligence too.

Snap & Go image recognition data capture

Snap&Go is the next generation of point of care data capture.

Its use of patented image-recognition technology is pioneering a new era in the recording of data capture.

Snap&Go can help OR and procedural areas run smoother and more efficiently:

• • Computer vision technology makes the task of capturing each item quick and simple.
  • In 3 seconds all relevant item data is recorded and can be shared with hospital systems.
  • Snap&Go doesn’t rely on the hospital’s Item Master, it taps into a global SKU database to ensure quick and easy item identification
  • It automates documentation, sending usage data straight to the patient file.

Snap& Go makes the job of surgical documentation easier for nurses, while at the same time ensuring OR business management also benefits.

So, let’s hear from nurses who have seen Snap & Go in action. What do they think about the benefits of this revolutionary POU data capture tool?

Nurse feedback on Snap&Go

Jenn is a Neurological Nurse who works in a major US Neuro Center with 25 ORs. Here’s how she describes the scale of the documentation task and why Snap&Go provides a good solution.

• • “When we do these procedures we have many implants, sometimes we’ll have 40 screws, a bunch of end plates, allografts, autografts – it takes a lot of documentation. I’ve reviewed Snap & Go and find that it can be very useful in the OR. As a Circulating Nurse my role is to do whatever the Surgeon needs, and take care of the patient. So, if I am always documenting and making sure the expiration date, and the numbers, and the sizes are all correct, it does take away from being able to anticipate what the surgeon neeDocumenting ds, where they are in the surgery. So, I do see a real benefit to Snap & Go.”
  • Another nurse commented, “The benefits of Snap & Go are the ease of use and getting all the information into the chart quickly.”
  • One nurse summed up the benefit of Snap&Go neatly, “Actually capturing every item used in a surgical procedure accurately.”

Take a look at our video short, which also includes nurse feedback.

The efficient and accurate documentation of products used in the OR is essential to optimize patient safety, operational efficiency, and case revenue. Traditional data capture methods present numerous challenges, all of which can be solved by embracing advanced point of care data capture tools.

Snap&Go uses the newest breakthrough technology and finally solves the issues of surgical documentation at clinical, operational and management levels.

If you are using unreliable barcode scanning or manual data-entry, contact us to find out how we can make your OR run more efficiently.

^*1 Nurses’ Time Allocation and Multitasking of Nursing Activities: A Time Motion Study – PMC (nih.gov)

^*2 Nurses’ Time Allocation and Multitasking of Nursing Activities: A Time Motion Study – PMC (nih.gov)