Are nurses required to read preop H&P

[Twm2021, BSN]

Does anyone know if the preop nurse is required to read the preop H&P of patients? I understand that the purpose of the preop H&P is to show that the patient is healthy enough to safely undergo anesthesia and surgery. Our surgeons sometimes bring them over at the last minute. Our preop checklist has us confirm that a preop H&P is on the chart but never have I been told we have to read them before sending a pt to the OR.  We had an out pt "infusaport removal patient" fall after surgery while using the restroom right before being discharged and the big issue for her attorney was that I didn't go and ready the H&P prior to walking her 6 foot to the toilet and leaving her 5 minutes, telling her not to get up, with the call bell while I called her family back to the postop holding area. She was fully alert but apparently had had a previous hip and back surgery and used a cane at home. She was told not to get up unassisted. Are nurses required to read preop H&Ps prior to helping patients?

[Rose_Queen, BSN, MSN, RN]

Well. It’s a safety check. Does the consent match what the patient says they’re having done match the H&P? What other quick tidbits can be gleaned from a quick look through the H&P? In my experience, they’re a page or less. And in my experience, the H&P is completed well before the date of surgery (but no more than 30 days) and all that is required of the surgeon day of surgery is a brief interval note stating they have assessed the patient, nothing has changed, proceed as planned. 

[CABGpatch_RN, BSN]

In the pacu, I have frequently learned that the patient is an insulin dependent diabetic by reading the H&P.  Didn't get that info from report from the OR.  I will always check a fingerstick post op is a patient is insulin dependent.  There have been times when I had to call anesthesia because patient needed D50 or administer insulin when there was not a single order addressing blood glucose.

I always read the H&P and/or problem list in epic, no matter what.  

[MelEpiRN]

I would think there are so many things you could learn from the H&P. Baseline mental status, baseline ambulatory status, prior anything that could affect your care...

[Hannahbanana, BSN, MSN]

I’m not going to quote the entire original post here, but there are issues that you might not have appreciated, some of which might not directly answer your question. I have reviewed many such cases. 

1) Your nursing care is based on nursing judgment, based on nursing assessment according to your nurse practice act and the ANA Scope and Standards of Practice, which are binding on every RN regardless of ANA membership or specifics in the local NPA (believe it or not, some states don’t have a free-standing NPA).

If I were reviewing this case for the plaintiff attorney I would emphasize that a complete assessment includes a complete review of recent medical assessment, I.e., the physician’s history and physical. This would be especially relevant if it had anything in it that should make you vigilant about her ability to move safely, be left unattended, or other factor that could contribute to a fall. Previous hip and knee surgery and cane use noted in the H&P would meet that standard. If that were on her chart and you didn’t even look at it, that’s not good assessment, so I would tell the atty that was nursing negligence whether I was advising plaintiff or defense (the hospital).

An RN doesn’t need a policy specifically covering every component of a nursing assessment but should know what assessment is needed; saying there’s no policy requiring you to read the H&P but only to observe its presence is not going to be much of a defense, especially as your oversight contributed to lack of safety for your patient. That made it possible for her to fall. Actual causation of her subsequent injuries is a medical opinion, but the fall was due to a nursing failure to assess.

2) If you don’t have previous experience c this patient using the toilet, as you didn’t in postop, it would have been prudent never to leave her unattended there after she has had sedation for a procedure. Fall risk management requires more than giving her the call light and telling her to call when she’s done. People often will not do that, for whatever reason— modesty, sedation, confusion, mobility impairment, all of the above. If you had to leave her, you could have delegated (an RN responsibility) an aide or another nurse to stand by. Yet you did not. And she fell. 
 

So, in answer to your question, yes, the RN is required to do a complete assessment for foreseeable care needs, including safety. In a day surgery setting (and any other, come to that), the H&P would certainly be important information that you couldn’t ignore because nobody told you that you had to pay attention to it. Lesson learned. 

[Twm2021, BSN]

It's not like I don't usually read the H&Ps. I was working in preop. Was asked to get the postip pt back in from pacu for the postop nurse who was too busy. After vital sign check pt insisted on going to restroom with toilet 5 ft from her gurney. I didn't see letting the pt pee on herself while I said sorry I must go read your H&P first as the correct response. Pt was fully awake and oriented from out pt surgery that could have been done in the office. But, next time that may be exactly what happens. 

[CABGpatch_RN, BSN]

2 hours ago, 210gtkka said:

I didn't see letting the pt pee on herself ....

I hope my comment did not make you feel defensive.  That was definitely not my intention. 

Regardless of reading H&P, my phase I post-op patients will always be offered a urinal or bedpan.  No one has to pee themselves.  But they are not getting up off the gurney in phase I. 

In phase II, I will personally get them up into a wheelchair and stay with them the entire time, UNLESS the CNA gets them up into a wheelchair and stays with them the entire time.  (thank goodness for our CNA's!)

This has been my experience.

[speedynurse, ADN, BSN, RN, EMT-P]

 

2 hours ago, CABGpatch_RN said:

I hope my comment did not make you feel defensive.  That was definitely not my intention. 

Regardless of reading H&P, my phase I post-op patients will always be offered a urinal or bedpan.  No one has to pee themselves.  But they are not getting up off the gurney in phase I. 

In phase II, I will personally get them up into a wheelchair and stay with them the entire time, UNLESS the CNA gets them up into a wheelchair and stays with them the entire time.  (thank goodness for our CNA's!)

This has been my experience.

Same for phase I and even sometimes for phase II.  I won’t allow a patient to go to an actual toilet until they are legit ready for discharge. Bedpan and toilet before that. On the way out, I will help them to the restroom to go. I have had a few patients that were just conscious sedation and wide awake upon discharge- I sometimes gave them privacy and stood right outside the bathroom door. But for the most part, I will stay in the restroom with them. 

[CABGpatch_RN, BSN]

2 minutes ago, speedynurse said:

 

Same for phase I and even sometimes for phase II.  

Same.  There are so many variables.  Definitely conscious sedation being one of them.  Post colonscopy is usually that case.

[Twm2021, BSN]

Definately not defensive. Thanks for posting your opinion. And it's been so long since we had cnas in phase 1 or 2 here. Can hardly get a CNA even in the ICU here.

[Mini2544, ASN, RN]

Hello!  Pre op nurse here...

To be honest, I skim the H&P to make sure the plan for the surgery is in there, the date is within 30 days and the review of systems is complete.  

Those are the areas we are required to check before the patient leaves the pre op area, so anything other than that is just part of past medical history.  

It sounds like someone is playing the blame game and taking it out on you.  

 

[Mini2544, ASN, RN]

Also, I have had patients (while working in post op) hours after GA go to the restroom by themselves.  I am always right by the door but I try to give them privacy since its an outpatient setting and these folks are rather healthy.  I don't know the exact type of anesthesia your patient had.  It also sounds like you all were a bit short staffed since you were rushing from pre op to PACU.  But of course..inappropriate staffing is never to blame for falls.  ?