Quick question, when a trauma case goes straight to OR bypassing preop holding do you as the circulator document for preop nurse. How can you do that documentation when the code trauma goes straight into OR from the ED. Hope my question is not confusing.
Jun 5, '11
we document on the "pre-op" paperwork section "Trauma pt taken directly to OR" and we may add any other info as necessary--ID band present on pt's left wrist, pt verbalizes understanding of surgery and/or blood transfusions (if no written consent is present and pt is awake/alert/not intubated), or family/next of kin who is present giving verbal consent. If no one present, and pt is not able to verbalize, I make mention of their mental status, but that's about it. I usually also indicate "report received from Trauma RN _____" and anyone else accompanying pt. When time permits, I do a more thorough review of the chart, but honestly, when its a trauma, the chart is usually minimal and its all I can do to be sure there is an ID band somewhere on the pt. Its nice to get allergies/history, but its not always possible and we do the best we can with what we've got. And make sure the documentation reflects that. Our pre-op nurses can take up to 45 mins to "check in" a pt for the OR.....in a trauma, you don't have that kind of time as I know you know
Jun 6, '11
We have a page to fill out on any patient who bypasses preop- whether it's a trauma straight from the ER or an ICU patient that preop can't take. We also have a checkbox there that says all of that info was deferred due to emergent status. It includes such things as pt or parent verified name/DOB, all consents signed and match H&P/progress note, any other facility or charity bands were removed, etc.
Jul 12, '12
Thank you all so much for the information. It is greatly appreciated.
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