Janice Kelly, MS, RN, NI-BC: No financial relationships to disclose
Learning Outcome: Eighty percent (80%) of learners will report that this session increased their knowledge of the Perioperative Nursing Data Set (PNDS) and its role as a standardized nursing language that supports accurate perioperative documentation, semantic interoperability, and the reuse of nursing data for quality improvement, benchmarking, research, and artificial intelligence in the post‑activity evaluation tool.
Overview/Abstract: Perioperative nurses deliver complex, high‑risk care that requires clinical judgment, coordination, and precision; however, historically, this work has not always been consistently or visibly represented in electronic health records. The Perioperative Nursing Data Set (PNDS) was developed to address this challenge by providing a standardized nursing language that accurately captures what perioperative nurses assess, decide, do, and achieve. This session explores the origins, structure, and ongoing evolution of the PNDS and its critical role in preserving nursing meaning as perioperative care becomes increasingly data‑driven.
Participants will be introduced to the PNDS conceptual framework, including its patient‑focused model, domains of care, and outcome‑oriented design. The presentation will demonstrate how PNDS concepts are clinically validated, coded, and mapped to national reference terminologies, supporting semantic interoperability across health information systems. Attendees will also learn how the PNDS serves as the foundation for the Standardized Perioperative Framework (SPF), which provides consistent documentation structure within the EHR and enables the reuse of perioperative nursing data.
Through real‑world examples, the session will illustrate how standardized documentation aligned with the PNDS and SPF supports quality improvement, benchmarking, research, analytics, and emerging applications such as artificial intelligence. By the end of the session, learners will better understand how intentional use of standardized perioperative nursing language strengthens documentation, enhances visibility of nurse‑sensitive outcomes, and positions perioperative nursing data as a trusted asset for clinical, operational, and technological advancement.
Description of Current State: Perioperative nurses deliver complex, high‑risk care that requires continuous assessment, clinical judgment, and timely intervention; however, the current state of perioperative documentation often fails to consistently and accurately reflect this work. Many organizations continue to rely on locally defined, vendor‑specific, or inconsistently structured documentation approaches that obscure nursing judgment and make perioperative nursing contributions difficult to measure, compare, or reuse. As a result, nurse‑sensitive outcomes are frequently underrepresented, and the true impact of perioperative nursing care remains largely invisible within electronic health records (EHRs).
Although the Perioperative Nursing Data Set (PNDS) was developed to address these challenges by providing a standardized nursing language, adoption and intentional use remain uneven across perioperative settings. In many cases, PNDS concepts are not fully leveraged as documentation anchors, leading to variability in how assessments, interventions, and outcomes are captured. Without consistent structure aligned to the PNDS, perioperative data cannot be reliably reused for quality improvement, benchmarking, research, or analytics, limiting the value of the data nurses generate every day.
These challenges are increasingly significant as healthcare organizations seek to leverage advanced analytics, interoperability, and artificial intelligence. Clean, standardized, semantically interoperable data are foundational requirements for these technologies, yet fragmented documentation practices undermine data integrity and trustworthiness. The current state underscores the need for greater awareness, education, and adoption of the PNDS and the Standardized Perioperative Framework to ensure perioperative nursing data accurately represent practice, support regulatory and quality expectations, and enable future‑ready, data‑driven perioperative care.
Description of Desired/Achievable State: In the desired and achievable state, participants will be able to explain how the Perioperative Nursing Data Set (PNDS) functions as a standardized nursing language that accurately captures perioperative nursing assessments, clinical judgment, interventions, and outcomes. Learners will be able to identify how PNDS concepts within perioperative documentation act as anchors for consistent, structured data within the electronic health record.
Audience Engagement: This session will use interactive polling questions throughout the presentation to engage learners, assess baseline knowledge, and reinforce key concepts related to the Perioperative Nursing Data Set (PNDS), semantic interoperability, and the Standardized Perioperative Framework (SPF). Polling questions will be used at multiple points to encourage participation, prompt reflection, and re‑engage the audience as new concepts are introduced.
Real‑world PNDS concept examples will be incorporated to help learners connect abstract terminology to familiar perioperative documentation scenarios, supporting active learning and practical understanding. Learners will be encouraged to reflect on how standardized nursing language is currently used—or could be better leveraged—within their own practice settings.
A facilitated question‑and‑answer period will be included to allow participants to ask questions, clarify concepts, and share experiences related to perioperative documentation, data standardization, and emerging uses of data such as analytics and artificial intelligence. These engagement strategies are designed to promote interaction, reinforce learning, and ensure participants remain actively involved throughout the session.
Additional Information:
Content/Topics: Overview and purpose of the Perioperative Nursing Data Set (PNDS) as a standardized perioperative nursing language
Structure, conceptual framework, and evolution of the PNDS, including domains, nursing process alignment, and clinical examples
Semantic interoperability and standards alignment, including PNDS mappings and support for consistent, reusable perioperative data
Application of PNDS through the Standardized Perioperative Framework (SPF) to support quality improvement, benchmarking, analytics, and artificial intelligence
References: Association of periOperative Registered Nurses (AORN). Perioperative Nursing Data Set (PNDS). Denver, CO: AORN, Inc.; 2025.
