Do you chart in the OR?

[AlisonBSN]

If so, what do you chart?

[ebear, BSN, RN]

CMD TPA,

We have an "Intraoperative Order Sheet" (or page on the computer) to cover that: prep solutions, intra-op xrays, meds. , foley, cultures, intra-op labs & blood admin.,irrigation soln., etc. Dr. signs in PACU

ebear

[TracyB,RN, RN]

If we don't have pre-printed pre-op orders for antibiotic, scd's, we actually write in the chart as a verbal order for EVERYTHING!!!!

Verbal order: insert foley immediately prior to surgical procedure

Verbal order: apply scd's to bilateral lower extremities

verbal order: bupivicaine 0.5% plain, 20ml to sterile field for intra-operative administration....

Yeah, it's that bad!

[ebear, BSN, RN]

TracyB!

Good grief!! Design thee an Intraoperative Order Sheet! That may be a very good project to undertake and should reflect very well on your next evaluation. Do y'all have paper charting? If so, it shouldn't be that hard to do. If y'all have computer charting, the computer person can assist and implement.

ebear

[kiwi77]

I am looking for information regarding documenting "orders" for specimens, cultures, meds etc. In 30 yrs, I have never functioned in the OR with written "orders" to send a specimen or place a medication onto the sterile field. I have always finctioned from a surgeon preference card for meds, foley, prep, etc. Or the surgeon directing care regarding these types of things. Does anyone have other experience? Thanks for your help!

cmd_tpa

The hospital where I work has an intraop order sheet with all that you've mentioned on it. The circulator ticks the box in each category for type of local, drains, foley, specimen, etc. Then signs and sticks in chart for surgeon to co-sign. This covers us for the drugs we pour on the back table, the type of irrigation used, pre-op antibiotics given....works real well.