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Do yuo review the intra-operative notes?

Nurses   (2,671 Views 6 Comments)
by CIRQL8 CIRQL8 (Member) Member

CIRQL8 has 13 years experience and specializes in Only the O.R. and proud of it!.

4,961 Profile Views; 295 Posts

A follow up question to the discussion of this thread in the operating room nurses' forum:

https://allnurses.com/forums/f39/do-you-chart-226553.html

How many of you who care for post-operative patients (med/surg, ICU, Etc.) read the nursing notes from the operating room?

And, what do you look for?

Do you pay attention to actual procedure(s) performed, patient position, drains, etc, etc???

Do you look at the anesthesia record to see the vital signs trend?

Just curious, but also because if I know what you are looking for, I will know more about what to chart!!

Thank You,

Dave.

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CIRQL8 has 13 years experience and specializes in Only the O.R. and proud of it!.

295 Posts; 4,961 Profile Views

Please excuse the typo in my thread name!!

(should be YOU, not yuo!!)

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i take care of A LOT of post ops and to be truthful, the only time I really look at the intraoperative notes is if I have concerns about something. If they get to the floor and have a sky high blood pressure, I will look at the trends and everything, but I'll tell you what I DO review everytime is the PACU notes. How much pain medication they required, their vitals, etc. Sometimes if they complain of weird pains, I will check out their positioning in the OR but the only things I am really concerned with are VS trends, intakes, outputs, and EBL. Don't really have time to look at much else!

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CarVsTree has 4 years experience and specializes in Trauma ICU, MICU/SICU.

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I work in trauma, so many times the IO notes are the only way to know exactly what they did. I agree with above poster though, PACU notes/report are indispensable for care of my patients.

What I Look For:

ATB's given and at one time. Lots of ancef for those open fxs, so I know when to give next dose.

Procedure(s) done.

I's and O's. Blood products, EBL.

I don't look at intraop for VS, I look to PACU for that, esp. if pt. isn't doing great.

Doc's postop orders.

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withasmilelpn has 18 years experience and specializes in Rehab, LTC, Peds, Hospice.

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I think specific proceedures and product names like the type of PICC or pacemaker/difibulator , drains, closures, etc. that may specifically effect their nursing care down the road. Patients forget by the time I see them in our rehab and sometimes nurse in this setting aren't up to date with the latest proceedures. It helps if all this information is legible (and hopefully copied with the medical records when sent to us). Is this what you are asking? (When I have time, I read pretty much everything!)

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purple1953reading specializes in ER OB NICU.

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Inaddition to what has been mentioned, I look for estimated blood loss, any reactions to anesthestics, any meds needed for high or low BP HR etc. I try to get all info I may need from the nurse giving me report. The new computer oriented care plans, counts, etc from OR are easier to read, but are usually not posted till two days after you get the patient.

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