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Charting positioning.


Specializes in Peds- ICU. Has 3 years experience.

Just wondering if follow nurses do a free hand pt positioning in the emr charting and at the end of the positioning note final position okay per dr ............

Rose_Queen, BSN, MSN, RN

Specializes in OR, education. Has 16 years experience.

Not freehand. We have dropdown boxes for position (lateral, supine, prone), arm position (tucked, armboard, arm sling for lateral), leg position (lateral, prone, supine, frogged), and positioning aides (axillary roll, head support, knee support, etc.). We also have defaults that these can be pre filled for us, just need to check that everything is correct. Part of our timeout includes checking the position with the surgeon and is documented as such.

canesdukegirl, BSN, RN

Specializes in Trauma Surgery, Nursing Management. Has 14 years experience.

For a minute, I thought you were asking how to document "free arm" positioning, as in draping for an axillary node dissection.

You should always document that positioning was approved by both the anesthesia team and the surgical team. If you don't have a drop down box that states both of these, you should write it in your nursing notes.