OR Verbal Order Documentation

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    I am researching information related to physician/surgeon's orders in the OR. Can some folks please share with me their hospital's policies regarding verbal orders in the OR and nursing's responsibility for required documentation? What are your hospital's policies for documenting the surgeon's verbal order for desired lab testing of specimens obtained in the OR? What kind of paper trail does your hospital have for following an order and a specimen? Thank you.

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  2. 3 Comments...

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    Gwen,

    At the facilities I have worked (all in NC) we just documented on the OR record under nursing comments...you will probably get a better response if you go to another BB...either AORN's 'membertalk' board or at www. periop.org/ BB.

    You may also want to check with your legal/risk department and see if they have an opinion. Kind of like the count sheets, it may vary from place to place.

    K. Lynn
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    Anything we do in the OR, we document on the OR record. For example, if the doctor asks us to give a gram of ancef, I document it on the meds portion of the record. If any specimens are sent, I tic this off as well. Even if the anethetist asks us to give vioxx in the hall outside the OR, I again would put this on the OR record only. I did write it out as an order once, and the doc. signed it, but stated that it need not be done this way. I realize that this could open up a big bad can of worms if he ever decided that he would not own up to it, but when I write it, I write ie) Ancef 1gm iv per Dr. Doolittle/mud RN
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    Thank you for the response. I really appreciate it!


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