Do you chart in the OR?

  1. If so, what do you chart?
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  2. 15 Comments

  3. by   Jarnaes
    In the OR we chart just about everything during the case. We have computerized charting.
    Of course it also depends on the type of case you are doing- you'll have more time during a total knee replacement than PE tubes.
    Things we cover while in the room: time in, time to surgeon, meds, implants, staff in the room, positioning and padding, bovie settings, TQ settings & time, cath, prep soln, type of anesthesia, areas shaved & prepped, x-ray... etc etc
  4. by   TracyB,RN
    Hummmppph... computer charting... don't have that, either : (
  5. by   inspir8tion
    We're still paper charting. There is a rumor that we will be getting computer charting "soon" (read probably by next year!)
  6. by   mikethern
    I like paper charting better than computer charting because you can get a head start by charting in the pre-op area and while standing next to the patient waiting for the anesthesiologist to intubate. Computer charting on the other hand requires you to turn your back on the patient.
  7. by   Sarah, RNBScN
    Case Room #
    Time in OR
    Time Anesthetic
    Time Surgery starts
    Time Surgery ends
    Time leave OR
    Time arrival to PACU

    Document surgeon, assistant, anesthesia, circulator and scrub nurse and anyone else in the room (sales rep for medical equipment, students, paramedics, etc)

    Procedure: Total abdominal hysterectomy

    Ditto: positioning devices, pt. position, solutions used, IV sites, foley, cautery pad and setting, count, etc...etc...

    Our OR record is carbon copy.

    Hope this helps. What are you looking for AlisonBSN? If you want a copy, let me know.
  8. by   Ailan
    Just curious, when a resident or other medical person in training perform all or part of the operation, is that information entered into the patient's chart? Perhaps in code? I would think information like that would have to be documented for legal reasons.
  9. by   TracyB,RN
    oooh, I would love to have a secret code.. Anyone present in the room is documented on the record. We have a spot for assistant on our 122 page carbon (just kidding)..

    Gotta get to work on developing that secret code for:

    Resident does everything while surgeon pretends to watch from corner
    Resident does horrible job at sutures
    Resident takes WAYYY too long to close... Ex... 1 inch incision should NOT take a 5th year 40 minutes to close.

    Hee hee hee... This list could get really long, really fast!!!!
  10. by   CMD_TPA
    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
  11. by   shodobe
    Quote from mikethern
    I like paper charting better than computer charting because you can get a head start by charting in the pre-op area and while standing next to the patient waiting for the anesthesiologist to intubate. Computer charting on the other hand requires you to turn your back on the patient.
    Nothing wrong with turning your back to the patient as long as you have eyes and ears in the back of your head like I do! I never could figure out why everyone has to think they need to keep an eye on the patient 100% of the time. What's the matter,have no faith in your anesthesia provider? We have had computer charting for 8 years and I can do my charting in less than 2 minutes and still can hear what is going on, don't need to look.
  12. by   brewerpaul
    Quote from mikethern
    I like paper charting better than computer charting because you can get a head start by charting in the pre-op area and while standing next to the patient waiting for the anesthesiologist to intubate. Computer charting on the other hand requires you to turn your back on the patient.
    Not ours-- we have laptops mounted on rolling stands so we can face the action and still chart.
    Depending on how many people are on hand, I sometimes try to get that same head start by putting in basic default information while others are opening the case supplies or while waiting for habitually late surgeons to arrive
  13. by   crackerjack
    Quote from CMD_TPA
    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
    i'm not sure what you're looking for. we don't have written orders for specimens...it's more like the surgeon mumbling, or alternatively YELLING, or just plain not classifying his specimen at all. some thing sare obvious, a gallbladder is a gallbladder is a gallbladder...but when you're removing sections of the colon, please give it a name doc and specify which end your putting the suture marker in...If a doc wants frozens we call path to come do them while we wait, take them down without a preservative on them. We have nothing in writing, i enter the orders in the computer during the case.

    tell me what you're looking for and maybe i'll give you something that helps and makes sense hehe
  14. by   ebear
    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

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