Nursing documentation shall occur for every procedure as per facility policy.
PRACTICE RATIONALE
2.12.1 Documentation of the diagnostic and/or operative procedure plus nursing
interventions is required by Accreditation Canada (previously known as the Canadian Council on Health Services Accreditation). All documentation is part of the patient’s legal chart.
The perioperative record provides an accurate contemporaneous account of nursing and/or medical activities throughout the perioperative phase. It provides a method to retrieve information for research, statistics (staffing, financial planning, patient acuity, and utilization), quality assurance, and legal/ risk management purposes. (Phillips, 2007) 2.12.2 Documentation shall be done in ink or
electronically (if implemented by the facility).
All entries are to be made in black pen. (Phillips, 2007; NATN, 2004) They shall be written clearly and in such a manner that the text cannot be erased. (NATN, 2004, p. l28)
2.12.3 Duplicate documentation by perioperative Registered Nurses and Anesthesiologists should be avoided.
Duplicate documentation may lead to questions regarding the accuracy of the documentation.
2.12.4 Documentation should be logically organized, easily communicated, and retrievable:
- use check boxes whenever possible; - avoid blank spaces, skipped lines or
crowded entries;
- write or print legibly using clear, objective language;
- use only health care facility approved abbreviations; and
- names and signatures shall be followed by the professional designation, e.g. RN.
Documentation indicating the care given and patient response provides continuity of care and ensures communication among team members.
2.12.5 A single line shall be drawn through an incorrect entry, initialed, and marked according to the health care facility policy.
Whiteout, eraser, or excessive cross-outs are not legally acceptable.
2.12.6 Late entries shall be accurately dated, timed and signed according to the health care facility policy. (NATN, 2004, p. 28)
Documentation that occurs at/or near the time of the event is considered to be more accurate and reliable.
2.12.7 Preoperative admission to the surgical suite should be documented and signed. The following information should be present and reviewed:
- patient identification band;
- identification card (if used in facility); - consent/documentation of consent
completed and signed;
- consent or withdrawal of consent for
Information is required to provide safe care; and to meet legal and health care facility requirements.
PRACTICE RATIONALE blood products, if applicable;
- surgical site identification; - history and physical assessment; - all diagnostic reports present; - preoperative vital signs ;
- allergies;
- NPO status;
- prosthesis (i.e. denture, glasses/contact lens, hearing aids, );
- jewellery,
- medication including herbal remedies; and
- presence of an advanced directive as necessary.
2.12.8 A preoperative assessment of the patient should be present and should include but is not limited to:
- level of consciousness; - baseline physical data; - psychosocial status; - relevant nursing diagnoses; - a nursing care plan; - cultural concerns; and - spiritual concerns.
Assists with the perioperative nursing care plan for positioning, to prevent injury, and to document any pre-existing conditions.
2.12.9 Perioperative event times should be defined and include but not be limited to:
- start of room setup; - patient entry to theatre;
- time of anesthesia start (induction); - surgeon enters room;
- position/prep start;
- procedure start (incision start); - procedure stop (dressing stop); and - patient exits theatre.
2.12.10 All personnel should use the same clock in theatre to document time.
An accurate recording of time is required for legal purposes.
Provides data (average times) for booking surgical cases.
Allows that all documentation done in that theatre is accurate to the same clock’s time.
2.12.11 Document name and professional designation of all personnel involved in patient care and any visitors.
This is required for statistical,legal and quality assurance purposes.
2.12.12 Document the patient's positioning including:
- restraints and positioning devices; - padding/supports; and
- skin condition.
Accurate documentation is a medico-legal
requirement. Information is necessary for monitoring patient outcomes and provides information in the event of an injury.
PRACTICE RATIONALE 2.12.13 Document any warming or cooling units
used, including the serial number of the unit, temperature setting, and placement.
Accurate documentation is a medico-legal
requirement. Information is necessary for monitoring patient outcomes and provides information in the event of an injury.
2.12.14 Documentation of a pneumatic tourniquet should include:
- time of inflation/deflation; - pressure setting;
- location and size of the cuff;
- unit serial number, model, or designated number;
- equipment check with a pressure gauge (for manual units);
- surgeon notification of elapsed time; and
- condition of the skin following removal of the cuff.
Accurate documentation is a medico-legal
requirement. Information is necessary for monitoring patient outcomes and provides information in the event of an injury.
2.12.15 Documentation of laser use should include but not be limited to:
- type of laser; - laser use time; - wattage;
- laser safety precautions taken; and - name of Laser Safety Officer (LSO),
etc. as per health care facility policy.
Accurate documentation is a medical legal
requirement. Information is necessary for monitoring patient outcomes and provides information in the event of an injury.
2.12.16 Documentation of the Electrosurgical Unit (ESU) should include:
- type of unit and serial number; - hair removal;
- location of dispersive electrode; - cutting and coagulation settings; - condition of skin after removal of the
dispersive electrode; and
- teaching done if patient refuses/cannot remove jewellery.
Accurate documentation is a medical legal
requirement. Information is necessary for monitoring patient outcomes and provides information in the event of an injury.
2.12.17 Documentation of insufflators used in minimally invasive surgery should include: - model and serial number;
- preset pressure, upper limit maximum; - flow rate; and
2.12.18 Documentation of mechanical irrigation devices regulating the infusion of irrigation fluid should include:
- model and serial number; - fluid type infused;
- preset pressure; and
Information is necessary for monitoring patient outcomes.
PRACTICE RATIONALE - volume used.
2.12.18 Documentation of surgical equipment used during a procedure.
- model and serial number;
This could include devices such as harmonic scalpel consoles.
2.12.19 Document the application of monitoring devices not documented by the
Anesthesiologist, or when doing local or monitored anesthesia care cases. 2.12.20 Document the skin preparation:
- skin integrity; - hair removal;
- type of solution used; and
- condition of prepped skin at end of surgery.
2.12.21 Document the surgical wound classification as per health care facility policy.
2.12.22 Document the following information for prostheses/implants:
- quantity, size and type; - manufacturer;
- lot number; and - serial number.
Records allow for recall of potentially defective prostheses and as a reference for removal.
2.12.23 Document packing including: - removal
- insertion
- number, size, and type; - location; and
- method of securing. (NATN, 2004, p. 235)
2.12.24 Document drains and/or catheters remaining in the patient. Include:
- number, size, and type; - location;
- method of securing; and - presence of a collection device. (NATN, 2004, p. 235)
2.12.25 Document specimens and/or cultures taken, as per health care facility policy. Document if sent to an area other than labs to which specimens are routinely sent.
PRACTICE RATIONALE 2.12.26 Document use of intraoperative X-rays,
fluoroscopy and type of patient protection including area(s) protected. (AORN, 2008, p. 312)
2.12.27 Document surgical counts and results and have them signed by those performing the counts as per health care facility policy.
2.12.28 Document medication, hemostatic agents, dyes, and irrigation administered by the surgeon and/or the nursing staff. Include: - dosage;
- volume; and
- method of administration
2.12.29 Document urinary output, blood loss and IV infusions, if not already documented by the Anesthesiologist, according to
procedure/health care facility policy. 2.12.30 Document the exact surgical procedure(s)
performed (confirm with surgeon) using only health care facility approved abbreviations.
2.12.31 Blood and blood products should be checked, administered, and documented according to the health care facility's policy.
2.12.32 Document the initiation of special precautions used with patients having a latex allergy, and/or malignant
hyperthermia.
2.12.33 Document any unusual occurrences, according to the health care facility policy, that are directly related to patient care and are pertinent to patient outcomes.
Incident reports are for the health care facility use only and do not become a permanent part of the patient record.
Documentation and incident analysis are part of a facility's risk management and can be used to increase safety and effectiveness in patient care. 2.12.34 The documentation method should reflect
patient care needs and be congruent with the health care facility policy.
Some facilities combine elements of different documentation methods to document care including but not limited to the following systems:
- critical path/variance analysis (care mapping); - focus/charting; and