Purpose/objectives: To redesign a postoperative flowsheet already used in clinical practice with patients who have undergone breast surgery to reflect documentation of assessments and interventions noted on each nursing visit.
Data sources: Memorial Sloan-Kettering Cancer Center Standards of Practice for Ambulatory Care, clinical experience, and published articles.
Data synthesis: A comprehensive flowsheet was redesigned to provide consistency in documentation and reflect current needs of patients who have undergone breast surgery who are in ambulatory care.
Conclusions: Implementation of the new flowsheet has decreased staff documentation time during busy office practices and accurately reflects the nursing care provided to patients after breast surgery.
Implications for nursing practice: Consistency in patient care can be maintained and efficiency can be increased with use of a comprehensive flowsheet.