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Documentation for the Care of the Patient in the Operating Room (2.10)

Documentation for the Care of the Patient in the Operating Room (2.10) - Policies, Clinical, UWHC Clinical, Department Specific, Surgical Services, Clinical

2.10

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

March 1996
ORIGINAL
 REVISION

October 2017
PAGE 1
OF 2
POLICY #

2.10
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
INTRAOPERATIVE DOCUMENTATION FOR
PATIENT CARE


I. PURPOSE

To reflect the intraoperative plan of care including assessment, planning, implementation, evaluation, and
expected outcome. Documentation provides a record of the intraoperative care received and the patient
outcome and is considered a legal document.

II. POLICY

A. Intraoperative documentation will be completed for every patient receiving care in the
intraoperative care area.
B. All procedures are documented. The Implant Record will be completed for every procedure
where an implant is utilized. All nonabsorbable items (i.e., plates, screws, nonabsorbable mesh,
skin, tissue/bone products, etc.) will be charted as an implant.
C. Intraoperative documentation will be completed by a Registered Nurse.
D. Staff will utilize their own password when documenting information in the computer
documentation system.
E. Military time will be used.
F. The primary nursing staff listed will not sign out on times listed for their lunches and breaks,
even though they have been relieved from their direct patient care responsibilities for that time
period.
G. The computerized documentation format will be utilized for all patients. When the computer
access is compromised, the hand written intraoperative forms “Operating Room Nursing
Flowsheet” UWH 18, “Operating Room Record” UWH 19, and "UWHC Surgical Verification
Checklist – Attending Surgeon" UWH form #4005929 will be used.
H. Patients who expire in the Operating Room (OR) suite/procedure room will be discharged with a
disposition of “Expired,” date and time of death documented, and destination of the body to the
“Morgue.” Enter within the Procedure description, “Patient expired at _________________.”
I. A Note will be used to document information not completely addressed within the
intraoperative documentation.
J. All medications used on the sterile field will be recorded in the intraoperative documentation or
Medication Administration Record (MAR) as appropriate.
K. Documentation by the monitoring nurse on local (moderate sedation) anesthesia procedures is
documented in the patient care record.
L. Amendments to the intraoperative documentation will be done via the Log Addendum.
M. Canceled Case
1. Scheduled procedure cancels after patient enters OR suite/Procedure Room:

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

March 1996
ORIGINAL
 REVISION

October 2017
PAGE 2
OF 2
POLICY #

2.10
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
INTRAOPERATIVE DOCUMENTATION FOR
PATIENT CARE


a. Procedure description should reflect cancelation.
b. Change procedure to “Canceled Procedure:”
2. Scheduled procedure cancels before patient enters the OR suite/Procedure Room:
a. Make notation in Procedure description of case canceling before patient entered the room.
b. Notify the Department Coordinator(s) or Charge Nurse. Note: Premature cancelation of
cases may impact others needing to document care within perioperative care areas and
have an impact on billing and statistics.

III. REFERENCE

A. AORN Guidelines for Perioperative Practice

REVIEWED BY:

Surgical Services Policy and Procedure Committee 2/2017
Ashley J. Rusch, Nurse Specialist, 10/2017

SIGNED BY:

Anne Mork, MHCDS, MS, RN
Interim Director, Surgical Services Department