Download

Click here to download the PDF.

Guideline for Nursing Documentation in Gastrointestinal Endoscopy

Click each section below to expand the content you would like to view.

Acknowledgments

Copyright © 2013, Society of Gastroenterology Nurses and Associates, Inc. (SGNA)
First published in 1989. Revised in 2002. Reviewed in 2005.

This document was prepared and written by the members of SGNA Education Committee and adopted by the SGNA Board of Directors in 2013. It is published as a service to SGNA members.

Contributors

James Collins BS RN CNOR, Chair
Cathy Birn MA RN CGRN CNOR, Co-Chair
Marcia L. Bouchard BSN RN CGRN
Donald R. Cooper MBA BSN RN CGRN LNC
Cynthia Edgelow MSN RN CGRN
Cynthia M. Friis Med BSN RN-BC
Laura Habighorst ADN RN CAPA CGRN
Rhonda Maze-Buckley RN CGRN
Joan Metze BSN RN CGRN
Candice M. Quillin RN CGRN
Ingrid K. Watkins, MSN FNP-BC CGRN
Conrad Worrell RN CGRN CSN

Reprints are available for purchase from SGNA Headquarters. To order, contact: Department of Membership Services

Society of Gastroenterology Nurses and Associates, Inc.

330 North Wabash
Chicago, IL 60611
Tel: (800) 245-7462 or (312) 321-5165 Fax: (312) 673-6694
Online: www.sgna.org
E-mail: sgna@smithbucklin.com


Disclaimer

The Society of Gastroenterology Nurses and Associates, Inc. present this guideline for use in developing institutional policies, procedures, and/or protocols. Information contained in this guideline is based on current published data and current practice at the time of publication. The Society of Gastroenterology Nurses and Associates, Inc. assume no responsibility for the practices or recommendations of any member or other practitioner, or for the policies and practices of any practice setting. Nurses and associates function within the limits of state licensure, state nurse practice act, and/or institutional policy.


Preface

Documentation development is guided by the use of the nursing process (assessment, planning, intervention, and evaluation) and helps establish consistent yet individualized plan of care for patients during endoscopy.

This guideline is intended to provide direction for healthcare providers in establishing consistent patient care documentation for endoscopy. Healthcare team members are encouraged to keep current on changes in documentation.

Documentation should clearly and uniformly record details that accurately describe situations or events occurring to patients undergoing endoscopy or related procedures. This guideline incorporates Centers for Medicare and Medicaid Services (CMS) requirements, as well as recommendations from The Joint Commission and Accreditation Association for Ambulatory Health Care, Inc. (AAAHC). Various members of the health care 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, the guideline is divided into three major components: Pre-Procedure, Intra-Procedure, and Post-Procedure. The intent is to provide information and criteria that can be selected in formulating an individualized document that meets the needs and requirements that conform to institutional policy.

Each institution must comply with applicable regulations and guidelines. These include but are not limited to state regulations, The Joint Commission guidelines, CMS requirements, and the institution’s standards for the monitoring of patients.

Definition of Terms

For the purpose of this document, the following terms are defined:

Hand off refers to an up-to-date exchange of information between caregivers regarding the patient’s condition, care, treatment, medication, services, and any recent or anticipated changes (Runy, 2008; The Joint Commission, 2012).

Intra-Procedure Phase begins with the time-out and at the beginning of sedation until the completion of the diagnostic or therapeutic procedure.

Medication Reconciliation refers to the accurate and complete reconciliation of medications across the continuum of care and includes name, dose, route, frequency, and purpose (The Joint Commission, 2012).

Post-Procedure Phase refers to the period of time from the completion of diagnostic or therapeutic procedure until the patient is discharged.

Pre-Procedure Phase refers to the period of time prior to the patient entering the procedure room.

Procedural team refers to the individual performing the procedure, a registered nurse, and a technician. It may also include anesthesia providers and other active participants who will be participating in the procedure.

Time-out refers to a verification process done immediately before starting the procedure where procedural team members agree, at a minimum, to the correct patient, correct procedural site, and correct procedure (The Joint Commission, 2013).

Universal Protocol refers to a process designed to avoid wrong patient, wrong site surgery and includes three components: a pre-procedure verification, site marking, and a time out (The Joint Commission, 2012).

Vital signs refer to a patient’s temperature, heart rate, respiratory rate, blood pressure, pain, oxygen saturation assessment, and may also include capnography. Components used may vary depending on procedural phase and institutional requirements.

Pre-Procedure Phase

During this phase, an age-specific patient assessment is performed by a registered nurse in order to determine appropriate nursing care, treatment, and services that meet individualized patient requirements.

Patients should be reassessed as determined by the institution and state protocols but at a minimum as determined by the care, treatment, and services sought, the patient’s presenting condition(s), and whether the patient agrees to care, treatment, and services (The Joint Commission, 2012).

The following data are recommended to be included during this phase:

1. Patient identification using a minimum of two patient identifiers (The Joint Commission, 2012) 
2. Physical assessment, individual needs, and procedure(s) to be performed (Burden, DiFazio, O’ Brien, & Dawes, 2000). Assessment to include, but not limited to: 

a.Date/time 
b. Baseline vital signs, including pain assessment. When applicable, may include: 

i. Cardiac monitoring 
ii. Capnography 

c. Warmth, dryness, and color of skin (Potter, Perry, Stockert, & Hall, 2012 ) 
d. NPO status (Afelbaum et al., 2011) 
e. Results and type of bowel prep (if applicable) (Bjorkman & Popp, 2006) 
f. Fall risk assessment 
g. Pregnancy status (American Society for Gastrointestinal Endoscopy [ASGE], 2012) 
h. Nutritional status 
i. Abdominal assessment 
j. Height and weight 
k. Activities of daily living: independent, requires assistance, total dependence (Burden et al., 2000) 
l. Emotional and psychological needs; spiritual and cultural beliefs (Burden et al., 2000) 
m. Possible abuse, neglect, or exploitation (The Joint Commission, 2012) 

3. Allergies and reactions to include prescribed and over-the-counter medications, herbals, food, environmental sensitivities, contrast media, and latex 
4. Signed/Witnessed informed consent 
5. Sedation scoring system to include but not limited to (Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy, 2008): 

a. Level of consciousness/mental status 
b. Airway/respiratory status/oxygen saturation 
c. Circulation 
d. Activity 

6. Disposition of patient valuables (e.g., glasses, jewelry, etc.) (Potter et al., 2012) 
7. Presence of removable dental appliances, loose teeth, glasses/contact lenses, hearing aids, piercings (Potter et al., 2012) 
8. Presence of prosthetic devices (e.g., hip replacement, valves), pacemakers, mechanical assist devices, internal defibrillators, and implantable devices (e.g., insulin pump) 
9. Medication reconciliation 
10. Labs or previous procedures results (if applicable) 
11. Intravenous line to include type, site, inserted by, rate of IV solution or presence of venous access device (O'Grady et al., 2011) 
12. Known significant medical diagnoses and conditions (e.g., gag reflex, current status of infectious disease/exposure, oncology treatments, physical disabilities, and conditions) (Burden et al., 2000) 
13. Past medical/surgical history and invasive procedures, history of complications, or reactions to previous sedation, analgesia, or general anesthesia (Burden et al., 2000) 
14. Physician required documentation 

a. History and physical 
b. American Society of Anesthesiologists (ASA) Classification 
c. Airway assessment (i.e., jaw and neck mobility) (American Association for the Study of Liver Diseases et al., 2012; Gross et al., 2002) 

15. Educational needs assessment to include (The Joint Commission, 2012): 

a. identification of barriers to learning 
b. learning style preference 
c. ability to comprehend information provided (Burden, et al, 2000) 
d. pre-procedure education 
e. post procedure instructions/patient or responsible person’s signature of receipt 

i. availability and name/access number of responsible adult 
ii. availability of safe transport home 

16. For pediatric patients: all items listed also to pertain to pediatric patients (Conners, Cravero, Lowrie, Scherrer, & Werner, 2013) 
17. Advance Directives, as applicable 
18. Hand-off communication to receiving caregiver 
19. Registered nurse signature, date, and time 

Intra-Procedure Phase

Every patient undergoing a diagnostic, therapeutic, or invasive procedure requires monitoring by a registered nurse or other qualified personnel (Society of Gastroenterology Nurses and Associates, Inc. [SGNA], 2012). Documentation should include the event, intervention (if necessary) and outcome.

The following data are recommended to be included during this phase (The Joint Commission, 2012):
1.  Time-out
2. Procedural team 
3. Equipment and alarms reviewed and set 
4. Ongoing patient assessment 

a. Vital signs (American Association for the Study of Liver Diseases et al., 2012). When applicable, may include: 

i.Cardiac monitoring 
ii. Capnography 

b. Pain assessment 
c. Abdominal assessment 
d. Level of consciousness 
e. Warmth, dryness, and color of skin 
f. IV maintenance 

i. Site 
ii. Type and amount of all fluids administered (including blood and blood products) (The Joint Commission, 2012). 

5. Patient positioning 
6. Name and dosage of all drugs and agents used (including oxygen and contrast media), time, route of administration, by whom, and patient response (The Joint Commission, 2012) 
7. Abdominal pressure if applicable 
8. Fluoroscopy exposure time, if applicable (SGNA, 2008) 
9. Equipment/accessories relevant to the procedure 
10. Grounding pad location and skin condition pre and post procedure 
11. Endoscopic therapies utilized during procedure (e.g., clips, stents, drains, bands, tubes) 
12. Adverse events 
13. Specimen collection 
14. Procedure performed/findings 
15. Start and end time. May include: 

a.endoscope insertion 
b. endoscope removal 

16. Disposition of patient; discharge criteria met 
17. Hand-off communication to receiving caregiver 
18. Signature(s), date, and time 

Post-Procedure Phase

The frequency of the assessment is determined by institutional/departmental policy, the physician and/or the registered nurse. The following data are recommended to be included during this phase (The Joint Commission, 2012):

1. Start time of post-procedure phase 
2. Ongoing patient assessment appropriate to patient’s age, needs, and procedure performed (American Association for the Study of Liver Diseases et al., 2012); 

a. Vital signs, including pain assessment. When applicable, may include 

i. Cardiac monitoring 
ii. Capnography 

b. Sedation scoring system to include but not limited to: 

i. Level of consciousness/mental status 
ii. Airway/respiratory status/oxygen saturation 
iii. Circulation 
iv. Activity 

c. Gag reflex if applicable 
d. Abdominal assessment 
e. IV maintenance 

i. Site 
ii. Type and amount of all fluids administered (including blood and blood products) (The Joint Commission, 2012). 
iii. IV disposition (i.e., maintain, lock, discontinue) 

3. Name and dosage of all drugs used (including oxygen), time, route of administration, by whom, and patient’s response (The Joint Commission, 2012) 
4. Intake and output 
5. Adverse events, interventions, and outcomes (The Joint Commission, 2012) 
6. Age specific, individualized discharge instructions reviewed and provided to patient and/or accompanying adult per institutional policy (The Joint Commission, 2012). May include, but not limited to: 

a. Follow-up and specific patient orders written by the physician 

i. Medication reconciliation 
ii. Diet and activity 
iii. Signs/symptoms of possible complications 
iv. Follow up appointments 

b. Emergency contact numbers 
c. Community resources available (if applicable) 
d. Educational materials (The Joint Commission, 2012) 

7. Disposition of patient 

a. Location (e.g., hospital room, home, x-ray) 
b. Patient’s belongings returned (Potter et al., 2012) 
c. Accompany responsible adult/transporter (Gross et al., 2002) 
d. Mode of transportation out of the department (e.g., ambulatory, stretcher, wheelchair) 

8. Hand-off given to subsequent healthcare provider, if applicable (The Joint Commission, 2012) 
9. Time of discharge and signature of discharge nurse 


Summary

This document has been compiled using current guidelines on documentation along with published data. SGNA anticipates that these recommendations will help healthcare providers establish a comprehensive institutional documentation policy.

As an additional resource, the Minimum Data Set is included as Appendix 1.

The Minimum Data set is defined as the basic essential elements necessary to document delivery of patient care in the gastrointestinal endoscopic setting. The Minimum Data set complements the Guidelines for Nursing Documentation by providing more detailed data sets.

References

Afelbaum, J. L., Caplan, R. A., Connis, R. T., Epstein, B. S., Nickinovich, D. G., & Warner, M. A. (2011). Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures: An updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology, 114(3), 495-511.

American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association Institute, American Society for Gastrointestinal Endoscopy, Society for Gastroenterology Nurses and Associates, Vargo, J. J., DeLegge, M. H., Feld, A. D., Gerstenberger, P. D., Kwo, P. Y., Lightdale, J. R., Nuccio, S., Rex, D. K., & Schiller, L. R. (2012). Multisociety sedation curriculum for gastrointestinal endoscopy. Gastrointestinal Endoscopy, 76 (1), e1-e25.

American Society for Gastrointestinal Endoscopy (2012). Guidelines for endoscopy in pregnant and lactating women. Gastrointestinal Endoscopy, 76(1), 18-24. doi:10.1016/j.gie.2012.02.029

Bjorkman, D. J., & Popp, J. W. (2006). Measuring the quality of endoscopy. Gastrointestinal Endoscopy, 63(4), S1-S2. doi:10.1016/j.gie.2006.02.022

Burden, N., DiFazio, D. M., O’ Brien, D., & Dawes, B. S. G. (2000). Ambulatory surgical nursing (2nd ed.). Philadelphia, PA: W.B. Saunders.

Conners, J. M., Cravero, J. P., Lowrie, L., Scherrer, P., & Werner, D. (2013). Society for Pediatric Sedation consensus statement: Core competencies for pediatric providers who deliver deep sedation. Retrieved from http://www.pedsedation.org/ documents/SPS_Core_Competencies.pdf

Gross, J. D., Bailey, P. L., Connis, R. T., Cote´, C. J., Davis, F. G., Epstein, B. S., Gilbertson, L., Nickinovich, D. G., Zerwas, J. M., & Zuccarro, G. (2002). Practice guidelines for sedation and analgesia by non-anesthesiologists: An updated report by the American Society of Anesthesiologists task force on sedation and analgesia by non-anesthesiologists. Anesthesiology, 96(4), 1004-1017.

O'Grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S. O., Lipsett, P. A., Masur, H., Mermel, L. A., Pearson, M. L., Raad, I. I., Randolph, A., Rupp, M. E., Saint, S., & the Healthcare Infection Control Practices Advisory Committee. (2011). 2011 Guidelines for the prevention of intravascular catheter-related infections. Retrieved from http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html

Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2012). Fundamentals of nursing (8th ed.). St. Louis, MO: Mosby.

Runy, L. A. (2008). Patient handoffs. Hospital and Health Networks. Retrieved from http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/Ar ticle/data/05MAY2008/0805HHN_FEA_Gatefold&domain=HHNMAG

Society of Gastroenterology Nurses and Associates, Inc. (2008). Radiation safety in the endoscopy setting [Position statement]. Chicago, IL. Author.

Society of Gastroenterology Nurses and Associates, Inc. (2012). Minimum registered nurse staffing for patient care in the gastrointestinal endoscopy unit [Position statement]. Chicago, IL. Author.

Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. (2008). Sedation and anesthesia in GI endoscopy [Guideline]. Gastrointestinal Endoscopy, 68(5), 815-826. doi:10.1016/j.gie.2008.09.029

The Joint Commission. (2012). 2012 Standards for ambulatory care. Oakbrook Terrace, IL: Author.

The Joint Commission. (2013). National patient safety goals effective January 1, 2013. Retrieved from  http://www.jointcommission.org/assets/1/18/NPSG_Chapter  _Jan2013_HAP.pdf

Recommended Reading

American Academy of Pediatrics, American Academy of Pediatric Dentistry, Coté, C. J., Wilson, S., & the Work Group on Sedation. (2006). Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: An update. Pediatrics, 118, 2587-2602. doi: 10.1542/peds.2006-2780

American Society for Gastrointestinal Endoscopy. (2008). Statement on routine laboratory testing before endoscopic procedures. Gastrointestinal Endoscopy, 68(5), 827-832.

Society of Gastroenterology Nurses and Associates, Inc. (2005). Minimum data set [Form]. Retrieved from http://www.sgna.org/Education/MinimumDataSet.aspx

Society of Gastroenterology Nurses and Associates, Inc. (2007). Guidelines for nursing care of the patient receiving sedation and analgesia in the gastrointestinal setting [Guideline]. Chicago, IL: Author.

The Joint Commission. (2010). Joint Commission international accreditation standards for hospitals: Standards lists version. Retrieved from http://www.jointcommissioninternational.org/common/pdfs/jcia/IAS400_standa rds_lists_only.pdf

Appendix 1: SGNA Minimum Data Set

Click here to view a PDF version of the appendix.

Login