Intraop Record

  1. When filling out the nursing record if a given area ie cautery or tourniquet is not used, what do other facilities do. Do you leave it blank, rationalizing if it wasn't charted, it wasn't done. Or do you put a line through it to show its not applicable? Or are there other methods?
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  2. 6 Comments

  3. by   Alliel
    I prefer to fill in all blanks with either a mark through or n/a. Alliel
  4. by   phill30
    I work in a hospital with 30 OR's
    currently most of the nurse leave these items blank
  5. by   angel03
    :angel2::angel2::angel2:I don't leave any blanks on my OR record.....I just recently had a friend who was deposed and the lawyer went line by line on both the OR record and the patient care plan......if not for excellent documentation...one can only guess...so my advice is to fill in every blank:angel2::angel2::angel2::angel2:
  6. by   mcmike55
    Most of our OR record consists of blocks to check, and blank lines for fill in the blank kind of info, like tourniquet pressure, time up and down, etc.
    When we don't use it, like our Cellsaver, etc, I and the rest of the nurses mark n/a or put some sort of slash through it.
    This way it doesn't look like an error of omission.
  7. by   Marie_LPN, RN
    Our facility requires "n/a". Just leaving it blank can make it look like somoene forgot to note something, but the n/a shows that it was read and answered.
  8. by   armyrn
    Quote from Marie_LPN
    Our facility requires "n/a". Just leaving it blank can make it look like somoene forgot to note something, but the n/a shows that it was read and answered.
    I agree. I also initial off when I cross it out.

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