I work in an EP lab where we place ICD's and Pacemakers. I would like to know from an OR nurse what we need to document. I think we OVER document. Of course we document, in room times, supplies and procedures, "Time out". What I don't know is do we have to document specific details like, "access obtained using a micro puncture needle, guide wire inserted, peel away sheath inserted, lead inserted, tested, sheath peeled away, RV lead sutured with O non absorbable suture...etc. We had a surgeon do a pacer for us and he thought we were writing out his OP note, which made me think, "I wonder if we are documenting WAY too much!
What is expected of the person who documents for a pacer or ICD?
What does the policy state? What does the recommendation from the specialty organization state? I know that when I've been in hybrid cases with our cath lab staff, they document times and what was placed, much like you do. There aren't any lead tests or sutures to record, but they capture everything else. As far as OR equipment and times, it is an expectation that we document when a tourniquet is inflated and deflated, as well as any vessel clamp and unclamp times with the exception of the aorta in cardiac surgery- the perfusionist is responsible for that.
It does sound like your are writing the surgeon's operative procedure note. Can you look at some medical records of patients who have been through your lab and see what the provider writes in his operative note. Then sit down with a manager and find any policies or procedure manuals and come to an agreement of what the nurse needs to be documenting?
I really hate over documenting!
I do too! Why do nurses do this? Are we covering our asses?
When I saw what the OR documents (hardly anything), I questioned that we are documenting way too much.
I am not in the OR but over-documenting really irritates me. Over-documenting devalues nursing information. The important info gets hidden in a pile of junk.
I work with some nurses who write up incident reports on the stupidest things. Like extremely stupid stuff. I think there was a period of time in nursing education where nurses were taught to make mountains out of molehills, all in the name of covering your ass.
But people who spend all their time covering their asses become what they are trying to cover, IMO.
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