Operating Room nursing documentation

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    Can anyone share how your documenting your care in the OR or RR..what charting system is being used? sopie, fdar?
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  4. 0
    We use Essentris electronic charting. We have 2 forms specifically the nurses fill out for every case 1) OR Intra-operative Record and 2) Pre/Post-Op Document. We are required to sign several other documents (Medication Reconcilliation, Procedure and Site Verification, etc...), but the first 2 are specific nursing forms.
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    My system uses Epic, and our OR staff charts using their OpTime module. It's a great system. If you have any questions, feel free to PM me.


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