Surginet Documentation

[SweetSouthernLove, ASN, BSN]

Hello All,

I had a question about our Surginet Documentation. My first and most important question is when I hit finalize in the Surginet Nursing OR document am I allowed to go back in at a later time and alter it without being penalized? I have asked numerous staff members at my hospital and no one can give me a straight answer. I have also asked to speak with the Clinical Nurse Educator about it on Monday but I really want to know the guidelines about this particular issue because it gives me much anxiety when charting and I cannot find a policy anywhere. I have done this currently because I was told that it was okay by a coworker and I felt the document really needed to reflect the procedure that we did, but then what is the point of having the finalization button there if it can just be modified at any time?

The reason that I am asking is due to surgeons changing their pre/postoperative medical diagnoses and surgical procedures. I often have to chase surgeons down to make them sign out with me after the procedure and often times they give me minimal surgical procedural information which often leaves me with having to hunt down their operative notes to recorrect and document the appropriate information in the chart. I feel this is not the appropriate practice and I want to know what others are doing and if anyone else is having similar situations as this. I am just trying to document the most correct information on my patients and this struggle is really making me uneasy as I know this is a legal document.

My second question is a little bit more of a general question but still has to do with the charting and is about the medications that I order from Pharmacy. So I order the medication under my surgeon's name but I am the one dispensing it to the field, so should the MAR indicate my name when documenting the administration or my surgeon's? I have also been told that either myself or the surgeon would suffice, but considering I did not order it I feel that it should be the surgeon's name rather than mine.

I am still learning everyday in this specialty, so I just want to be safe and legally correct for both my patients and myself. Again, I am going to speak to the CNE on Monday to try to dig up further clarification. Any feedback would be helpful!

[WhoDatWhoDare, BSN, RN]

I'm not familiar with your particular charting system, but if you are going into the chart to update the procedure and post-op diagnosis, I'm not sure why that would result into an issue for you legally speaking, unless you are going back 24 hours or more after to make those changes.

In regards to documenting the administration of the meds ordered, my practice is that if I gave it, e.g. pre-op antibiotics, versed, I document that I administered it... If it's a med that is on the sterile field and given by the doc or resident during the case, they are entered as who gave it, regardless if I retrieve the med before/during the case. You mention ordering the medication.

[SQueenRN, BSN]

Don't finalize until you're totally sure everything is correct and complete. You can close out the screen and it will save everything. Finalize means finalize. In the MAR, I document who gave the med whether it's me, anesthesia, or MD.

[Rose_Queen, BSN, MSN, RN]

My facility doesn't use Surginet, but we are allowed to go in and make necessary changes as long as it is documented as an addendum to the record. Our OR records are automatically closed at 48 hours post surgery. To change documentation, we must click that we are making an addendum, and then we must fill in a reason for doing an addendum. Our most frequent one is when we get notified by the tissue tracking team that something wasn't marked as a tissue implant because our tissue tracking system labels everything as non-tissue and we have to manually change it, which gets missed sometimes (especially when we have multiple implants). I honestly don't go back and change procedures and diagnoses. I confirm verbally with the surgeon before he/she leaves the room. If the note is completed before I finish the record, I'll double check. If it's not, I asked, I typed in what they said. Medications- I document who actually gave the med. If it was the surgeon, it's given by the surgeon. If it was the PA, it's given by the PA. Anesthesia documents everything they give themselves. In our system, we automatically get a list of everyone in the room and just have to click who actually gave the med. It's the same as on the floor when nurse A documents a med that was given by nurse B- nurse A's name is on the record as documenting, but the option of "given by another" is clicked with a comment saying who gave it and why they aren't documenting it.

[SweetSouthernLove, ASN, BSN]

Thank You Rose & Others!

The addendum is the correct protocol at my facility also. I am trying to lasso my surgeons down even though it seems silly I am still learning all the procedures myself! I appreciate the input and thanks again!

[Rose_Queen, BSN, MSN, RN]

Does your facility require a debriefing at the end of every surgery? This, along with specimen verification, surgical count correct or not, recovery concerns, and other important patient care considerations should be discussed at the end of the procedure before the surgeon leaves the room.