documentation

  1. The current controversy around my dept is regarding the intra op record. One RN states that for instance if a procedure doesn't require the cautery machine the area for that should just be left blank his rationale is if it is left blank it is considered not be applicable; stemming from his training...if it wasn't charted it wasn't done.
    Another RN says we have to draw a line through it to show we haven't over looked any areas. Can anyone shed some light on this, what does other OR depts do?
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  2. 4 Comments

  3. by   eyelady2
    Blanks are not considered good documentation. Actually, when you have an inspection (state, Medicare, etc.) - they may note this when they do a record review. We have developed our intraoperative sheets to reflect our current practice as much as possible (we are a specialty surgical center); we tried to use a check-off box system to decrease the amount of writing we do; however, lines should not be left blank on a chart. Perhaps your risk manager could give a review of this for your staff (proper way to document and why - we found this helpful as well). Hope this helps. Eyelady.
  4. by   angel03
    Quote from eyelady2
    Blanks are not considered good documentation. Actually, when you have an inspection (state, Medicare, etc.) - they may note this when they do a record review. We have developed our intraoperative sheets to reflect our current practice as much as possible (we are a specialty surgical center); we tried to use a check-off box system to decrease the amount of writing we do; however, lines should not be left blank on a chart. Perhaps your risk manager could give a review of this for your staff (proper way to document and why - we found this helpful as well). Hope this helps. Eyelady.
    :angel2::angel2:I agree blanks are not acceptable...it only takes a second to slash or write N/A.....
  5. by   carcha
    Every thing has to be filled in to reduce the risk of confusion. While many of you may know that a "blank"means something wasent used others may think you forgot to fill it in. We are also banned from using checks and must state yes, no, none ect ect for each question, the side, site the lot.
  6. by   shodobe
    We do all of our charting on a computer and everything is either fill in the blank or info from a drop-down menu. We can't leave anything blank if it is critical, computer won't let us. We can type in a dialoge of observations if needed. Mike

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