Postoperative nausea and vomiting (
PONV) remains a common postoperative complication that causes patient discomfort and increases health care costs. Clinicians use the American Society of PeriAnesthesia Nurses (
ASPAN) guideline to help prevent and treat
PONV. However, the lack of standardized terminology in the electronic health record (EHR) and the lack of clinical decision support tools make it difficult for clinicians to document guideline implementation and to determine the effects of
nursing care on
PONV. To address this, we created a concept map of the
Perioperative Nursing Data Set (PNDS) that illustrates the relationship between elements of this standardized nursing terminology and the
ASPAN guideline, using the Systematized Nomenclature of Medicine-Clinical Terms multidisciplinary terminology to fill any gaps. This mapping results in a standardized dataset specific to
PONV for use in an EHR, which links
nursing care to nursing diagnoses, interventions, and outcomes. The mapping and documentation in the EHR also allows standardized data collection for research, evaluation, and benchmarking, which makes
perioperative nursing care of patients who are at risk for or experiencing
PONV measureable and visible. Distributing this information to perioperative and
perianesthesia nursing personnel, in addition to implementing risk assessment tools for
PONV and clinical support alerts in electronic documentation systems, will help support implementation of the
PONV clinical practice guideline in the EHR.