Charting in the OR

suzanne4, RN · Apr 11, 2006

The scrub only signs that they did their part of the count, that is in all facilities. Soem also require that each member of the OR team actually sign off on the record.

The circulator is reponsible for the documentation.

DM74LA · Apr 11, 2006

What exactly gets charted though? I know that the counts are charted, but what else? Anything about the pt? ID verified? Condition during surgery? Tasks performed during surgery? What color clogs the scrub is wearing?

MissJoRN, RN · Apr 12, 2006

You aren't an OR, nurse, right? My post is assuming that you are not-

We attest that the pt was checked for identity, site, and allergies (in addition to the seperate "correct site form" and signing off on the pre-op assessment sent from day surgery or the floor) and that the pt is "emotionaly ready" for the procedure

We chart who was in the room- the surgeon, med students, assistants, CRNA/MDA, RN, scrub person, rad tech, and any reps or observing student nurses, etc

What kind of anesthesia was given (the categories- IVA, general, type of block... not the actual agents and meds)

We chart the time- in the room, start of surgery, closing, and leaving room, also what room we're using (so we can track- do some rooms' cases have more postop infections than others?)

There is a standard classification for wounds by the AORN clean, tidy surgical wounds through contaminated trauma wounds- this number is charted. Also the Anethesia Society of America has an classification for the pt's general health pre-op and that is number is charted.

The position of the patient, any props, pillows, foam, stirrups, or gel pads are charted as well as who helped position the pt.

If an electro-cautery machine was used- what type, which unit (each one has a number- "should" be the same as the room but we move them around) and where the grounding pad was placed and by whom, if used

If any other equipment was used, and often the assigned number of the unit- endoscopic video, laser, ultrasound, certain suction setups, high flow irrigators, cataract machine, etc, etc

Pre-op and post op skin assessment for breakdown, abrasions, burns, rashes, etc

Were DVT wraps and/or TEDs worn? From the floor or from the OR? On before induction of anesth?

If radiology was used- what type, how long, how was pt protected?

We chart that counts were done, by whom, signed, and that they were correct (or not and what actions taken)

If a cath was done or foley placed and all the "usual" info you're used to charting with that

What meds were used by the surgeon- everything from saline irrigation to steroids, local, antibiotic irrigation, narcotic placed in implant, chemo placed, eye gtts, etc

Any packing or drains temporarily left in place, size, location

Any permanent implants go on their own page- manufacturer, serial number, lot number, expiration date, any info they give.

I think that's about it, if I'm forgetting something major, I'm sure someone will notice!

DM74LA · Apr 12, 2006

Wow, that seems like a lot to know, esp for a nurse new to the OR who is unfamiliar with the equipment. Of course, I guess some procedures have more to chart than others.

Is most of this narrative charting? Or are there standardized forms other than what you already mentioned?

I'm guessing that meds that the Dr. gives are written on a MAR? Does he sign for them?

Thanks for the detailed explanation.

MissJoRN, RN · Apr 12, 2006

All that fits on a form shorter than you'd expect, LOL. Whether it's a paper chart or computer system most are set up in a way that you check or cirle what applies. The NANDA style "careplan" is also built right into the form and we just inital that goals were met per the interventions we checked off- for instance "maintain pt safety" was partially met when I ensured the pt was in a correct supine position (checked) with maybe gel pads under pressure areas and ulnar protectors to support and protect the most commonly pinched nerves in the arm (checked)

Even some of our meds that are very commonly used are preprinted so we just need to fill in the total given. As far as meds we name the drug, give the total, where it was given (incisional irrigation, right eye topical, right eye intraoccular, flush ASH) and when (usually simply pre-op, post-op, intra-op) also who gave it- often the surgeon, sometimes the circulator. Anesth charts their own. No real "MAR" used here!

The equipment is part of why OR orientaion is so long... by the time you know how to use it independantly (in your appropriate role) and have the routine and pace down efficiently enough to work without a preceptor you'll have no problem taking 30 seconds to name the unit on your flow sheet :)

I would recommend that you flip to the operative section of your patients charts if they are post op to see how your form looks, hopefully that's possible on your floor, sometimes it takes a few days for the computer chart to be printed or it might not be printed at all in your hospital, I guess, and sometime you can't access another departments flow sheets. But if you can... do... it helped me before I came to the OR