Intra-Op Record & Delay Documentation?

  1. Does your intra-op record contain a place to document a delay, and delay reasons for starting of a case?
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  2. 10 Comments

  3. by   Marie_LPN, RN
    Yes it does. The delay field is a yes or no pulldown bar. The reason has to be typed in. We have to add that after the miraculous discovery that disappearing doctors were the majority of the reasons there was a delay.
  4. by   grimmy
    [font="book antiqua"]not only is there a place to document a delay, but we write up a quality report for delays, too. in ormis, the nurse can write just about anything pertinent in the nurses' notes.
  5. by   Rnn2003
    Yes, we also have a drop down box to chart delays or you can type it in. Most of my delays seem to be H&p update needed or Surgical site marking not done and last but certainly not least the good old surgeon or Aneth. late
  6. by   sharann
    Our OR nurses almost never put the delay or code down. Is there a reason for this as it happens very often.There is a simple checkbox on the form. Is there a reason I am not aware of for them not doing this?
  7. by   Marie_LPN, RN
    Too busy, i would guess. It's not a "mandatory field" to fill out, and on the quick cases, some skip it.
  8. by   sweet31eve
    We have that too. When we first went to computerized charting we TRIED to use it...but then an ortho surgeon saw one of my co-workers pick that the cause of the delay was that the surgeon was late. They have morning office and are to have their first case at 12....well, it turns out to usually be 1 or 2. He made my co-worker take it off his chart and he went to our manager and threw a fit...imagine an ortho dr. doing that!!! LOL So we are not allowed to document reason for delay in procedure.
  9. by   Marie_LPN, RN
    So we are not allowed to document reason for delay in procedure.
    So this way, the staff can be blamed for all delays, because there's nothing to prove otherwise. (which is what happened until we complained about how many time WE heard how WE could improve turnover time, nevermind about the disappearing surgeons...)
  10. by   sweet31eve
    Exactly. We are constantly getting complaints from patients because of delays in procedures. Not only are thesurgeons late-they over book. They will be assigned to do a case, but also be assigned to assist on a total with their partner...so there a patient will sit all day NPO and vent. And rightfully so! We really don't have a problem with other specialties like we do ortho, but we do fight over our general surgeons with the endoscopy department....you know..."Don't send for the next patient just yet...I have a few quick scopes to do"...yeah right!!! We all understand emergencies happen and things can go wrong in a previous case, but c'mon!!!!!
  11. by   Marie_LPN, RN
    Our ortho and ENT dept. is the best when it comes to staying on time. It's our general dept. that's a couple of hours behaind, for no good reason.
  12. by   sharann
    Thats what I thought. I think that if the staff gets flak for delays though, they should chart it somewhere.

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