Perioperative Nursing Data Set
The idea for the Perioperative Nursing Data Set (PNDS) originated in the late 1980s when the AORN Board of Directors identified a need for a national computerized database for perioperative nursing. 1 In 1993, the AORN established a task force to develop this perioperative nursing language. This group included masters and doctoral prepared perioperative nurses with expertise in informatics, research, management, education, and clinical nursing. This group, with several subgroups, began a six-year project to create the PNDS. Besides using the literature and reviewing documents in developing the terminology, studies were done with experienced perioperative nurses to test the validity and relevancy of the PNDS in various practice settings from pre-admission to discharge. The goal was to make visible to administrators, financial officers, and healthcare policy makers patient problems that perioperative nurses manage. 2
Currently the PNDS includes over 2100 terms focused on scheduling operative and other invasive procedures. 3 It includes terms for nursing diagnoses, nursing interventions, and nurse-sensitive patient outcomes. It was recognized by the ANA in 1999. The guiding premise of the language was to assist perioperative nurses to document the care they give and provide a foundation for examining and evaluating the quality and effectiveness of the care. It provides a foundation to compare clinical data and for benchmarking as well as to measure outcome data and evaluate the quality and effectiveness of care. It is updated annually and mapped to code sets including CPT-four, ICD 9-CM, ICD-10-PCS, and SNOMED-CT. ® It can easily be integrated into an agencies’ EHR through the use of AORNs Syntegrity.
References
1. Bigony L. Charting the course with the PNDS. OR Nurse. November 2010;4(6):15-21.
2. Beyea SC. Standardized nursing vocabularies and the peri-operative nursing data set. CIN Plus. 2000;3(2):1:5-6.
3. Procedure list. 2014; http://www.aorn.org/Syntegrity/Procedure_List/ . Accessed October 12, 2014.
Additional Resources for the CCC
Bigony, L. (2010). Charting the course with the PNDS. OR Nurse, 4(6), 15-21. doi: 10.1097/01.ORN.0000388945.34674.98.
Description and history of the PNDS.
Stanton, C. (2009, May). A new era with the Syntegrity Standardized Perioperative Framework. Retrieved October15, 2014.
Description of AORN's Syntegrity which is integrated into an EHR and uses the PNDS unambigous terms to document.
Beyea, S. (2000). Perioperative data elements: interventions and outcomes. AORN Journal, 71(2), 344-352.
DeBlieck, C., LaFlamme, A. F., Rivard, M. J., & Monsen, K. A. (2013). Standardizing documentation for postoperative nausea and vomiting in the electronic health record. [Case Reports]. AORN Journal, 98(4), 370-380. doi: 10.1016/j.aorn.2012.12.021
Doyle, M. (2006). Promoting standardized nursing language using an electronic medical record system. AORN Journal, 83(6), 1336-1342.
Junttila, K., Salanterä, S., & Hupli, M. (2005). Developing terminology for documenting perioperative nursing interventions. Int J Med Inform, 74(6), 461-471
Kleinbeck, S. V. (1999). Development of the Perioperative Nursing Data Set. AORN Journal, 70(1), 15-18, 21-23, 26-28.
Lamberg, E., Salantera, S., & Junttila, K. (2013). Evaluating perioperative nursing in Finland: an initial validation of perioperative nursing data set outcomes. AORN Journal, 98(2), 172-185. doi: 10.1016/j.aorn.2013.06.011
Morton, P., Petersen, C., Chard, R., & Kleiner, C. (2013). Validation of the data elements for the health system domain of the PNDS. [Validation Studies]. AORN Journal, 98(1), 39-48. doi: 10.1016/j.aorn.2013.05.008
Perioperative Nursing Data Set (PNDS), 3rd Edition. AORN, Denver, CO
Petersen, C., & Kleiner, C. (2011). Evolution and revision of the Perioperative Nursing Data Set. AORN Journal, 93(1), 127-132. doi: 10.1016/j.aorn.2010.07.015
Westendorf, J. J. (2007). Utilizing the Perioperative Nursing Data Set in a surgical setting. Plastic Surgical Nursing, 27(4), 181-184. doi: 10.1097/01.PSN.0000306181.50071.39
Westra, B. L., Bauman, R., Delaney, C. W., Lundberg, C. B., & Petersen, C. (2008). Validation of concept mapping between PNDS and SNOMED CT. [Comparative Study
Research Support, Non-U.S. Gov't]. AORN Journal, 87(6), 1217-1229. doi: 10.1016/j.aorn.2007.11.036
