Perioperative Nursing Data Set (PNDS) PNDS
Latest Update via UMLS 2011 Original Publication 1999 Created in 1993, PNDS is maintained by the Association of periOperative Registered Nurses (AORN) Board of Directors (Taulman & Latz, 2011). PNDS is a “standardized language that addresses the perioperative patient experience from pre-admission until discharge; and describes the nursing diagnoses, interventions and patient outcomes that make up the nursing processes” (Taulman & Latz, 2011). It provides a consistent method for classifying and documenting perioperative patient care across the surgical continuum, allowing for the monitoring and benchmarking of patient outcomes and operating room efficiency. The PNDS provides a framework to standardize clinical documentation within an EHR. PNDS is the only perioperative nursing language recognized by ANA.
Process for Updating/Publishing Standard
A change in evidence-based practice per AORN standards and guidelines triggers the need for an update. Once a change is identified, the AORN PNDS team reviews concepts for relevancy and appropriateness, retires outdated concepts, edits existing concepts, or develops new concepts. Updated/New/Retired concepts are then either:
Reviewed by an AORN-PNDS task force; or
Reviewed at the AORN Annual Conference by the Educator Specialty Assembly, which rates new concepts for their relevancy and appropriateness to perioperative practice.
Usage/Activity
Once AORN experts have reviewed the concepts, AORN board members perform the last review of the concepts for relevancy and appropriateness and approves or rejects the changes. PNDS is typically revised every four years to five years; the latest version is the third edition, released in 2009, which added new concepts. In 2016, the SNOMED CT nursing problem list replaced NANDA nursing diagnosis list. A new PNDS version dealing with perioperative patient safety interventions (e.g., the surgical “timeout” process) is in development and new nursing interventions will be submitted, to introduce more granular concepts that represent perioperative nursing care; release date will be determined based on priority of information.
The current usage demographic includes more than 400 hospitals, research facilities, surgery centers and educational institutions. A license is required, and cost varies between hospitals and researchers. Researchers can use PNDS free, but health care organizations pay based on the number of operating rooms (ORs) and operative procedures performed.
Identifying Challenges and Opportunities within Standard Nursing Terminologies 19
It is difficult to standardize the implementation of the PNDS into multiple software applications because of the various strategies to configure the PNDS terminology within each EHR database and application leads to inconsistent implementations, and interoperability and harmonization issues. Some software developers have packaged the PNDS in their products as an offering but may not provide the most current version or allow customization resulting in a lack of consistent use of the PNDS.
Opportunities
PNDS is the only nursing language focused on perioperative nursing process and practice and most of the PNDS concepts were created in SNOMED CT specifically for the PNDS language. The 3rd version of the PNDS was mapped to SNOMED CT in 2011. The SNOMED CT mappings were reviewed and validated in 2012 with no corrections and they are currently (2017) undergoing a review cycle.