Documenting an in/out implant

memolei · Feb 16, 2020

We document "in and out" next to the implant, sizer, screw, etc that does not remain in the patient if it was newly placed in the patient and does not remain in the patient. We do this not only for tracking and charging purposes but also for reordering purposes. Implants that are removed, that was in the patient prior to procedure starting, I put under specimen as "gross".

Not sure if this helps ?‍♀️

Editorial Team / Admin · Feb 16, 2020

If it's the current surgery and the patient doesn't leave the OR with it in place, we document it as wasted. There's a comment box we can use for why (trial pin, incorrect size, etc.)

If it's from a previous surgery, then we utilize the explant option to remove it from the patient's record. That way, if there's any recalls at a later date, this patient won't receive the call/letter as they no longer have the implant. We also send to pathology for gross only if requested by surgeon or for device failur and document in our specimen area.

Example for an explant: cardiac patient left the OR with sternal wires (considered an implant at my facility). The following day, the patient returns for a reexploration due to bleeding. The previous day's sternal wires are cut and disposed of. The nurse goes into the implant section, chooses explant option, and selects the wires that were implanted the day before. Surgeon does not request they be sent and it isn't a device failure issue, so wires are disposed of as sharps.

Example for a waste: orthopedic patient for ORIF. Implant 14mm screw. X-ray shows screw is not long enough. Screw removed, replaced with 16mm screw. We would document that 14mm screw as a waste and the 16mm screw as an implant.