DocumentationSTANDARDS AND GUIDELINESGuidelines for Documentation inthe Gastrointestinal Endoscopy SettingDisclaimerThe Society of Gastroenterology Nurses and Associates, Inc. assumes no responsibility for the practices or recommendations of any member or other practitioner, or for the policies and proceduresof any practice setting. The nurse and associate function within the limitations of licensure, statenurse practice act, and/or institutional policy.This guideline is based on current understanding and practice in the field. Eachgastrointestinal/endoscopy unit is responsible for establishing its own documentation proceduresand for creating its own forms, allowing for the differences in operation of each unit. The sampleforms illustrated herein are not necessarily suited for any unit other than the unit that developedeach form. They are printed here with the permission of the contributing facilities.PrefaceDocumentation development is guided by the use of the nursing process (assessment, planning, intervention and evaluation) to establish an individualized plan of care for the patient while in the endoscopy unit. This guideline is intended to provide direction for individual endoscopy units in establishing consistent patient care documentation. These documentation guidelines meet requirements for patients receiving sedation. A reduced requirement for documentation may apply dependent onyou institutional policy for non-sedated patients. Documentation should clearly and uniformly record details that closely describe situations or events occurring to patients undergoing endoscopy or related procedures. This guideline incorporates Centers for Medicare and Medicaid Services (CMS) requirements and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommendations. Various members of the healthcare team may be responsible for documenting specific items in the patient record.In order to provide information that is easily adaptable to each patient care environment, theguideline is divided into three major components: Pre-Procedure, Procedure and Post-Procedure. The intent of the guideline and the accompanying outline is to provide information and criteria that canbe selected in formulating an individualized document that meets the needs and requirements to conform to institutional policy and to the particular endoscopy setting.Definition of TermsFor the purpose of this document, the following terms are defined:Vital signs: temperature, heart rate, respiratory rate, blood pressure, pain, and oxygen saturation assessment.DocumentationJCAHO: Joint Commission for Accreditation of Healthcare Organizations.CMS: Centers for Medicare and Medicaid Services.AAAHC: Accreditation Association for Ambulatory Health Care.Pre-Procedure Phase: the period of time prior to the beginning of the procedure.Procedure Phase: from the initiation of sedation and analgesia, when used, or the initial step of an invasive procedure, until completion of the diagnostic or therapeutic intervention.Post-Procedure Phase: from the completion of the diagnostic or therapeutic intervention until the patient leaves the facility.Section 1:Pre-Procedure PhaseAn age-specific patient assessment is performed and documented by a registered nurse. The assessment factors should include physical, psychosocial, current medications, treatment, and previous medical, anesthetic and drug history. Review of the patient’s symptoms and history will supply any pertinent information to be documented.All documentation should include time of performance and name of person performing the assessment or intervention. The frequency of the assessment is determined byinstitutional/departmental policy, the patient condition, the physician and/or the registered nurse. JCAHO recommendations and CMS requirements for the Pre-Procedure Phase are included in the following:1. Time of assessment2. Telemetry, if applicable.3. Oxygen saturation if sedation or analgesia is anticipated.4. CO2 monitoring (optional)5. Level of consciousness/mental status6. Disposition of patient valuables (i.e. glasses, jewelry,etc.)7. Baseline pain assessment using institutionally approved pain scale with identification ofarea, duration and type of pain8. Warmth, dryness and color of skin9. NPO status10. Bowel prep compliance (if applicable)11. Current medications and time of last dose(s) including aspirin, non-steroidal anti-inflammatory drugs, anticoagulants, sleeping medications, tranquilizers, over-the-counter drugs, herbal agents or illicit drugs.12. Allergies and reactions to medication, food, contrast or latex including OTC and herbals13. Presence of removable dental appliances, loose teeth, glasses/contact lenses, hearing aids14. Presence of prosthetic devices (e.g., hip replacement, valves)15. Airway assessment (e.g., jaw and neck mobility)16. Intravenous line: type, site, inserted by, rate of IV solution or presence of venous accessdevice17. Pregnancy status18. Physical assessment appropriate to the patient’s age, individual needs, and procedure to beperformed19. Labs or previous procedures results (if applicable)Documentation20. Patient concerns21. Emotional status, psychological, spiritual, cultural status22. Assessment for potential abuse23. Educational needs assessment with identification of barriers to learning24. Known significant medical diagnoses and conditions including current status of infectiousdisease/exposure, physical disabilities, and conditions25. Known significant surgical and invasive procedures, history of complications or reactions toprevious sedation, analgesia, or general anesthesia26. Validation of correct patient/correct procedure27. Admitting registered nurse signature/timeSection 2:Procedure PhaseEvery patient undergoing a diagnostic or therapeutic, or invasive procedure requires monitoring by a registered nurse or other qualified personnel. Whatever method is employed, documentation should include event, intervention (if necessary) and outcome. Each facility must comply with applicable regulations and guidelines, including state regulations, JCAHO guidelines, CMS requirements, andthe facility’s standards for monitoring of patients. JCAHO recommendations and CMS requirements forthe Procedure Phase are included in the following:1. Vital signs2. Telemetry, if applicable3. Baseline and ongoing pulse oximetry is required for patients undergoing sedation andanalgesia.4. CO² (optional)5. Level of consciousness/mental status6. Continuous pain assessment using institutional approved pain scale with documentedresponse to intervention7. Warmth, dryness, and color of skin8. Procedure(s) performed9. Physician(s), registered nurse(s) and support staff involved in the procedure10. Name and dosage of all drugs and agents used (including oxygen), time, route ofadministration, by whom, and patient’s response11. Type and amount of all fluids administered (including blood and blood products)12. Equipment/accessories used (i.e. cautery, laser,etc.)13. Implantable devices (i.e.stents, tubes, etc.)14. Unusual events, interventions and outcomes15. Patient status at the end of procedure16. Type of specimen(s) obtained and disposition17. Post-Procedure findings18. Signature(s) required19. “Time Out” initiated by the physician to confirm the right patient/right procedureDocumentationSection 3:Post-Procedure PhaseThe frequency of the assessment is determined by institutional/departmental policy, the physician and/or the registered nurse. JCAHO recommendations and CMS requirements for the Post-Procedure Phase are included in the following:1. Time of arrival in post-procedure area2. Vital signs3. Pulse oximetry is required until return to pre-procedure baseline for patients who receivedsedation and analgesia.4. Continuous pain assessment using institutional approved pain scale with documentedresponse to intervention5. Level of consciousness/mental status6. Warmth, dryness and color of skin7. Name and dosage of all drugs used (including oxygen), time, route of administration, bywhom, and patient’s response8. IV fluids administered and/or discontinued including blood and blood products9. Unusual events, interventions, and outcomes10. Physical assessment appropriate to age, patient needs, and procedure performed11. Disposition of patient (hospital room, home, x-ray, etc.), and with whom12. Report given to subsequent caregiver13. Mode of transportation (ambulatory, stretcher, wheelchair, etc.)14. Name of person responsible for outpatient at discharge15. Age specific discharge instructions and educational materials given to outpatient and/oraccompanying adult, who verbalizes or demonstrates understanding and signs form.16. Discharge criteria applied17. Time of discharge18. Signature of discharge nurse19. Discharge instructions per institution policy to include follow-up and specific patient orderswritten by the physician.ConclusionBy combining the JCAHO recommendations and CMS requirements for documentation along with published data and input gathered from the membership, SGNA anticipates that these recommendations will provide guidance to each endoscopy unit staff in establishing a comprehensive institutional documentation policy.ReferencesAmerican Society of Anesthesiologists. (2001). Updated practice guidelines for sedation and analgesia by non-anesthesiologists. [Practice guideline]. Park Ridge, IL: Author.Documentation Committee on Drugs of the American Academy of Pediatrics. (1992). Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeuticprocedures. Pediatrics, 89, 1110-1115.Health Care Finance Administration. (1993). Generic Quality Screen Guidelines, Exhibit 37.Washington, DC: Author.Joint Commission on Accreditation of Healthcare Organizations. (2003). Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, IL:Author.Kost, M. (1999). Conscious sedation: Guarding your patient against complications. Nursing. 29 (4): 34-39.Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. (2002).Sedation and monitoring of patients undergoing gastrointestinal endoscopic procedures.Gastrointestinal Endoscopy, 2, 626-629.Society of Gastroenterology Nurses and Associates, Inc. (2000). Guidelines for nursing care of the patient receiving sedation and analgesia in the gastrointestinal setting. [Guideline].Gastroenterology Nursing. 23:125-129.AcknowledgmentsFirst edition 1989, revised 2003.Prepared by the Education Committee of the Society of Gastroenterology Nurses and Associates, Inc. (SGNA) chaired by Trina Van Guilder, RN,BSN,CGRN.Adopted by the Society of Gastroenterology Nurses and Associates, Inc. Board of Directors 2003. Published as a service to members by the Society of Gastroenterology Nurses and Associates, Inc. Copyright © 2003, Society of Gastroenterology Nurses and Associates, Inc.DocumentationOutline for Form PreparationThe following outline is included to ease the preparation of a form to be used for the acquisition of data, procedure and post-procedure documentation and statement of patient’s dispositionI.Pre-Procedure PhaseScheduled ProcedureB. Patient identification1. Demographic dataa. Nameb. Date of birthc. Unique patient identification numberd. Phone number2. Physician3. Referring physician4. Time of arrival5. Communication barrier6. Impairments7. Responsible adult fordischarge/accompanied byC. Health History1. Past procedure(s)2. Previous problems with anesthesia orsedation3. Chief complaint4. Present illness5. Allergies including reactions: food,medication, latex6. Current medication, time of last dose(s)7. Level of consciousness/ mental status8. Level of comfort9. Bowel preparation10. NPO status11. Baseline vital signs and pulse oximetry12. Weight in pounds/kilogramsAirway assessment (neck and jaw mobility, dentition)D. Medical History1. Heart disease, pacemaker, implantedcardioverter defibrillator, dysrhythmias,valvular heart disease2. Hypertension3. Lung/breathing problems (e.g., asthma,COPD, sleep apnea)4. Liver disease (e.g., jaundice, hepatitis,cirrhosis)5. Pancreatic disorders (e.g., pancreatitis,6. rders (e.g., seizures,disease10.nia, IBD/IBS, diverticulosis,13.sing institutional scale, duration, location)rE. Surgisthetic devices (e.g.,stents, valves, joint replacements)sF. Family Historycancer2. olyps3. IBDdiabetes)Neurological disoCVA, ALS, MS)7. Kidney8. CancerBleeding or blood di9. sorders, includingtransfusion historyGI problems (e.g., peptic ulcer disease,hiatal herpolyps)11. Arthritis12. Pregnancy statusGlaucoma14. Pain (u15. Othecal1. Implanted pro2. GI surgerie1. ColonPDocumentationG. Social Historye.g., ETOH, illicitrugs)H. Venous Access Devicee used Solution and rate/flushResultsJ. P 4. Methods (e.g., pamphlet, video) gM. Presence and Disposition of Appliances(e.g., dentures, hearing aids, contacts,. Vulnerable Adult yes/no; Social Servicesgnaturease 1. Substance abuse (d 2. Smoking history1. Time started2. Site3. Type of devic . 45. Inserted by I. Laboratory Test atient Teaching1. Patient knowledge of procedure2. Barriers to learning3. Interventions to learning barriers 5. Demonstrates understandin K. Pre-Procedure Nursing NotesL. Informed Consent Obtainedglasses) N Notified yes/noO. Admitting Nurse SiII. Procedure PhProcedure TimeB. Validation of correct patient/correct e (“Time out”)B. S rse(s) Support staffC. Medication (including oxygen)ed Administered by response D. V ns of skin Level of consciousness/mental status sponse E. E 3. The dingin condition c. : settings,e. evice: purpose (e.g.,ding tubes: size,, lot number Dilators: size, type 4. amples). Documentation of anyindwelling devices left in patientStarted Completedprocedur taffPhysician(s)Registered nu Technicians1. Time administer2. Dosage/liters3. Route/method . 45. Patientital Signs1. Blood pressure, heart rate, respiratio2. Oxygen saturation3. Warmth, color and dryness . 45. Level of comfort/requipment/Accessories1. Endoscope2. Monitoring equipmentrapeutic modalities (examples)a. Cautery: type, setting, groun pad site & pre/post skb. Laser: type, settings, safetyprocedures followedArgon plasma coagulator flow rate, grounding pad site &pre/post skin conditiond. Band ligators: number placed Injection d sclerotherapy, tattooing, contrast medium)f. PEG/PEJ, stents, fee type, manufacturer . g h. Other (e.g., snare)Diagnostic modalities (ex a. Probes (e.g, pH, rectal) b. Manometry catheterc. Other (e.g., biopsy forceps)dDocumentation. FluoroscopyG. Imaging(e.g., videotape, photography)H. S y icrobiology Procedure Performed and Post-ProcedureJ. Nursing Observation Notestions andre3. ost-procedure assessment beforeK. Nurse/Staff Signature(s)F 1. Time 1. Methodpecimens1. Biopsy2. Cytolog3. M4. OtherI.Diagnosis 1. Unusual events, interven outcomes2. Toleration of procedu P transfer to recoveryPhysician’s signatureIII. Post-Procedure PhaseA. Time of Arrival to Post-Procedure Area. Vital Signs and oxygen saturation fortal Status t/ResponseE. Ven d (including bloodts) Time discontinued 3. Condition of siteB patients who received sedationC. Level of Consciousness/MenD. Level of Comfor ous Access1. Total amount infuse and blood produc . 2 F. Medications1. Time administered2. Dosage3. Route4. Administered by5. Patient responseNote: Usage of only acceptable medication names and dosage abbreviations.G. Oral Fluid ToleranceH. Report Given to Subsequent CaregiverI. Discharge InstructionsGiven by Given toVerbalizes or demonstrates understanding Signature of patient and/or accompanyingadultDischarged according to criteria or byphysician discharge orderJ. DispositionDestinationAccompanied by (name of individual) Mode of transportationK. Time of DischargeL. Nursing Observation NotesUnusual events, interventions and outcomesM. Discharge Nurse SignatureDischarge Instructions to OutpatientsA. Type of Procedure PerformedB. Activity1. Normal2. Restrictions (e.g., driving, operatingmachinery, working)C. DietNormalModificationsa. Special diet instructionsDocumentationF. Medication Instructionsb. Fluids Restrictions NPO (e.g., untilanesthetic worn off)1. Continue2. DiscontinueAvoidance of alcohol (state number ofhours)3. New medications prescribed4. Interactions of medications with foodand other drugs D. Post-Procedure Complication Symptoms 1. List symptoms specifically (e.g.,abdominal pain, fever, evidence of bleeding)G. Specimen ResultsMethod for obtaining results (e.g., callphysician’s office)2. Instructions for notifying physician orobtaining emergency assistance (include physician office/answering service phone numbers) H. Additional Pertinent InstructionsFollow-up visit with physician Referrals, if appropriateE. Instructions for Symptoms and SensationsExpected as Normal, and RemediesSore throat - throat lozenges, gargle withwarm water, etc.Redness at IV site - apply warm compress,etc.Gaseous discomfort - belching, passingflatusI. Signatures1. Patient and/or accompanying adult2. Nurse discharging the patientA copy of the discharge instructions or written documentation is given to the patient and one is kept in the patient’s chart.。
