PNDS Resources

AORN offers a number of resources offering additional information about the Perioperative Nursing Data Set (PNDS) and standardized nursing languages, including links to related websites, sample documentation, and publications.

About Standardized Nursing Languages

PNDS Implementation

PNDS Documentation Resources

Surgical Asepsis Activities
Proposed Data Fields for Preoperative Documentation Records (PDF)
Proposed Data Fields for Intraoperative Documentation Records (PDF)
PNDS Nursing Care Plan: Preoperative (PDF)
PNDS Nursing Care Plan: Intraoperative (PDF)
Sample Introperative Patient Record (PDF)
Sample Preoperative Assessment Form ( PDF)
Sample PACU Stage I Record (PDF)
Sample PACU Stage II Record (PDF)

Software Vendors Authorized to use the PNDS

Health Language Inc.

McKesson

PNDS Audio Sessions from AORN Congresses available for purchase:

AORN07-1668 PNDS Connects Practice & Safety Initiatives
The PNDS provides a framework that is useful not only for documentation management, but measuring patient outcomes. Using the PNDS outcomes link the perioperative nurse and nurse leader to practice and safety projects. This session will discuss the application of PNDS outcomes and use of the PNDS benchmarking data to such initiatives as the Institute for Healthcare Improvement’s 100K Lives Campaign, Surgical Site Infection Prevention programs, and the JCAHO’s National Patient Safety Goals.

AORN07-1686 PNDS at the Enterprise Level
What is the value of the PNDS across a multi-system enterprise? What electronic reports are useful to perioperative nurse administrators? This presentation will provide current information about the PNDS from a management perspective as well as the actual experiences of a 186-hospital system.

AORN07-1644
Partnering To Achieve Staff Acceptance of Electronic Documentation Including Transition to PNDS
Many staff nurses in operating rooms document how care is delivered on paper. In preserving the future of operating room nurses, it is essential to transition staff toward electronic documentation and use of PNDS. The audience will learn strategies shared between a vendor and hospital as they jointly prepare OR staff for acceptance of electronic documentation by exposing staff to PNDS through use of preference cards.

AORN07-1633 Controlling the Chaos
This presentation will discuss the ongoing challenge of addressing increasing OR volumes through applying PNDS benchmarks to improve on-time first case starts, effectively maintining block utilization, controlling volume variation per day by applying "smoothing" concepts and addressing daily add-on caseload.

AORN07-1617 AMB - Out of Sight, Not Out of Mind: Postoperative Surveillance in the Ambulatory Setting
Just because our patients are only with us for a few hours does not mean our work is done once they leave. There is a gold mine of information just waiting for us to tap. We are all used to doing a follow-up call within 2 days of the patient's surgery, but what if we were able to learn more about patient outcomes? What if their information could help us with future patients? At the Medical Arts Surgery Center @ Baptist in Miami, patients receive a 14 day post-op call. The data collected is used to improve clinical, service, fiscal, and employee excellence. Just as PNDS helps with validating our practice during the patient visit, this post-op surveillance can lead to performance improvement and success.

AORN06-9325 A Perioperative Dilemma: Measuring the Difference a Nurse Makes
Organizational factors within the perioperative setting have a significant influence on patient outcomes. These include a variety of nursing-specific variables such as nurse certification, 24-hour staffing, the performance of multidisciplinary code drills, nurse staffing, and agency use. Identifying the best structures, processes, and outcomes to measure are necessary to improve the quality of health care. The Perioperative Nursing Data Set (PNDS) provides guidance in these relationships. Meg Johantgen, Robin Newhouse.

AORN06-9577 PNDS: Jumping into the Real World
Integrating the PNDS into everyday work can be a challenge. This workshop offers an opportunity to work in a small group with an expert facilitator to develop staff education; write policy, procedures, and competencies; build a novice nurse internship; or set up electronic perioperative record screens. Information about changes in the 3rd edition of the Perioperative Nursing Data Set will be shared. Cecil King, Susan Kleinbeck, Paula Morton, Mary Salreno, Kathie Shea.

AORN06-9316 Faculty - Introducing Perioperative Nursing to Academia
This session will illustrate how the Perioperative Nursing Data Set (PNDS) can facilitate teaching/learning about the specialty of perioperative nursing. Target audience members are nursing faculty, staff educators, and novice nurses interested in applying the PNDS to their daily practice. Joy Don Baker, Susan Kleinbeck.

AORN05-8223 PNDS and the Perioperative Electronic Health Record
Mary A Salreno, Susie V.M. Kleinbeck, Robyn Maher, Synthia Yarorough

AORN05-8254 PNDS and Perianesthesia Practice
Cindy Ripplinger, Cindy Ladner

PNDS-Related Publications
Petersen, C. (2007). Ed. Perioperative Nursing Data Set Revised 2nd ed. Denver, AORN, Inc.
The "Second Edition - Revised" features new exemplars illustrating how others have since incorporated the PNDS in various clinical settings. A new chapter on the PNDS Dashboard explains how the PNDS Benchmark Database can help your facility measure its performance against national averages for similar health care facilities. Other valuable additions and updates include sample competency statements, policies and procedures, care plans, program outlines for educators, critical pathways, and performance appraisals - all written using the PNDS language.

Kleinbeck,S.(2004) PNDS @Work: Building a Perioperative Patient Record. Denver, AORN, Inc.
First in the series. This publication focuses on building a patient record--both written and electronic--using the Perioperative Nursing Data Set (PNDS) vocabulary. A six-step implementation process guides the reader through creating a nursing care plan using the PNDS through planning for and testing software before going "live." The book contains practical tips from nurses who have been through the process of implementing an electronic patient record that incorporates the PNDS.

Kleinbeck,S.(2004) PNDS@Work: Policies, Procedures, & Pathways. Denver, AORN, Inc.
Second in the series. Maintaining current, accurate, and readily available perioperative care directives is a major challenge. Where does a nurse start when assigned to manage such an important yet burdensome task? What best practices should be considered?

Kleinbeck,S.(2005) PNDS@Work: Encouraging Perioperative Clinical Experiences. Denver, AORN, Inc.
Third in the series of five. There are many benefits of exposing nursing students to perioperative experiences.This book demonstrates the advantages of a periopertive clinical experience for students (eg, knowledge and skills gained and student learning outcomes). It explains the perioperative nursing process, the value of concept mapping, and useful examples for designing a student learning experience in a perioperative setting.

Kleinbeck,S.(2005) PNDS @Work: Staff Nurse Development. Denver, AORN, Inc.
Fourth in the series. Material taught to nurses in a busy perioperative department must be succinct, be applicable to perioperative nursing, and provide a return on investment. Using the principles of adult education makes learners' acquisition of knowledge, competence, and understanding easy. The purpose of this book is to illustrate best practices of staff nurse development using the vocabulary common to all perioperative nurses--the Perioperative Nursing Data Set (PNDS).

Kleinbeck,S.(2005) PNDS@Work: Clinical Competencies and Job Descriptions. Denver, AORN, Inc.
Fifth in the series. Documenting the competence of health care providers is a necessity, not a luxury. In the interest of the public good, nurses' competence is measured when beginning employment and regularly thereafter. This book illustrates how the recognized perioperative nursing vocabulary--the Perioperative Nursing Data Set (PNDS)--can be used to successfully reflect patient outcomes in the competency statements and job descriptions of perioperative RNs.

The entire PNDS@Work Series can be purchased as a set (ISBN: MAN-405)
This series of books describes how the Perioperative Nursing Data Set (PNDS) can be used in everyday nursing practice.

PNDS-Related Periodicals
2007 Fire Safety in Perioperative Settings. (December 2007), AORN Journal, (Vol. 86, Pages S141-S145)

Westendorf, Jennifer J. Utilizing the Perioperative Nursing Data Set in a Surgical Setting. [Article.] Plastic Surgical Nursing. 27(4):181-184, October/December 2007. (OVID) AN: 00006527-200710000-00003.

Park, H-A, Lee HJung, Yoon, K. (September 2007), The Perioperative Nursing Data Set in Korean: Translation, Validation, and Testing. AORN Journal, 86(3), 424-445.

2006
Doyle, M. (June 2006), Promoting standardized nursing language using an electronic medical record system. AORN Journal, 83(6), 1335-1342.

2005
Kleinbeck, SM, Dopp, A. (July 2005) The Perioperative Nursing Data Set—A new language for documenting care. AORN Journal, 82(1), 50-57.

2003
Parker, N; Kuehl, N. (June 2003)
Programs for nursing students and faculty members of schools of nursing offer specialized instruction:Tuesday, March 25, to Wednesday, March 26, 2003. AORN Journal, 77 (6), 1130-1132.

Dreger V. (Jan-Mar 2003) Focus. The Perioperative Nursing Data Set (PNDS): a new language for documenting nursing care. Insight: The Journal of the American Society of Ophthalmic Registered Nurses, 28(1), 15-7. (OVID) AN: 2003067229 NLM Unique Identifier: 12703252.

2002
Kleinbeck, S. V. M. (2002) Revising the Perioperative Nursing Data Set. AORN Journal, 75(3), 602-610.
This article addresses the updates and revisions to the PNDS in the second edition. It provides information about the review process as well as a summary of the changes. Examples are provided to help readers understand both the review process and the revisions.

2001
Beyea, S. C. (2001), The Ideal State for Perioperative Nursing Documentation. AORN Journal, 73(5), 897-901
Describes strategies toward developing surgical records that share information effectively through the use of structured vocabulary and a thoughtful approach to clinical practice. Discussion begins to explore the development of standards for paper or electronic documentation through collaboration with other stakeholders, including anesthesia providers, surgeons, clinical directors, and informaticians. Includes two careplans that integrate the Perioperative Nursing Data Set addressing the immediate preoperative and intraoperative phases of care.

Beyea, S. C. (2001), Data Fields for Intraoperative Records Using the Perioperative Nursing Data Set. AORN Journal, 73(5), 952-954
Describes work by the Nursing Practice Committee to identify data elements for an intraoperative clinical record. Describes structural data elements and compares them to nursing data elements, and begins to explore the relationship of professional nursing practice and documentation.

Veit, K., & King, C. (2001), Perioperative Nursing Data Set for the Adult patient Having a Cystoscopy. Seminars in Perioperative Nursing, 10(1), 47-53
Presents nursing care plan for patients undergoing a cystocopy using the Perioperative Nursing Data Set (PNDS)developed by a student intern working with a Perioperative Clinical Nurse Specialist. The care plan includes nursing diagnoses, nursing interventions, and patient outcomes with their unique identifiers from the PNDS.

2000
Beyea, S. C. (2000), Perioperative Data Elements: Interventions and Outcomes. AORN Journal, 71(2), 344-352
Describes the six years of effort by AORN to identify and validate nursing intervention statements and nurse-sensitive patient outcomes. Presents the goals, strategies, and methods of the various subcommittees. Discusses implications for educators, managers, and clinicians.

Beyea, S. C. (2000), Structural Data Elements-Standardized Terms and Definitions. AORN Journal, 71(3), 541-549
This article describes how structural elements were developed and validated by the Data Elements Coordinating Committee. It includes the glossary of AORN Structural Data Elements and definitions.

Kleinbeck, S. V. M. (2000), Dimensions of Perioperative Nursing for a National Specialty Nomenclature. Journal of Advanced Nursing, 31(3), 529-535
Original research report supporting the domains of the Perioperative Patient Focused Nursing Model. Principal Components analysis explained 46.4% of the variance among the NANDA nursing diagnoses selected by 239 perioperative nurses as representing perioperative nursing practice.

1999
Beyea, S. C. (1999), Standardized Language-making Nursing Practice Count. AORN Journal, 70(5), 831-838
Provides information about standardized nursing languages and the vocabularies that have been recognized by the American Nurses Association. Describes the value of a standardized nursing vocabulary to the nursing profession.

Fox, I., & Brown, T. (1999), Affecting Patient Care with Perioperative Clinical Pathways. Surgical Services Management, 5(10), 41-47
Describes the use of the Perioperative Nursing Data Set in an automated clinical pathway system. Explains the development process and discusses the benefits of the pathway system to resource and outcome management.

Kleinbeck, S. V. M. (1999), Development of the Perioperative Nursing Data Set. AORN Journal, 70(1), 15-28
Discusses development and testing of the Perioperative Nursing Data Set and its conceptual framework, taxonomy, and possible clinical applications. Presents in detail the conceptual model for the PNDS: the Perioperative Patient Focused Model.

Seifert, P. C. (1999), The Perioperative Nursing Data Set: Power is Knowledge. AORN Journal, 70(1), 9-11
President's message describing the relationship of the PNDS to professional nursing practice.

1997
Killen, A. R., Kleinbeck, S. V. M., Golar, K., Takahashi Schuchardt, J., & Uebele, J. (1997), The Prevalence of Perioperative Nurse Clinical Judgments. AORN Journal, 65(1), 101-108

1996
Kleinbeck, S. V. M. (1996), In Search of Perioperative Nursing Data Elements. AORN Journal, 63 (3), 926-931

1995
Kneedler, J. A., & Sexton, L. R. (1995), Perioperative Data Elements Will be Critical for Nurse Managers. Surgical Services Management, 1(1), 45-49