We have antibiotics charted in 3 places:
Hospital record (different software system)
Anesthesia record (on paper)
Allergies, we have charted and listed on the Hospital record on admission. Why would we/do we have to document them out separately on the OR record or can we put 'see patient's chart' and be covered.
Any suggestions? Just looking for what other places do before going further (which will be needed).