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Documenting Implants

Operating Room   (8,398 Views 12 Comments)
by buck70 buck70 (Member) Member

buck70 specializes in OR.

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We are having a debate in our OR: Can you "trace/track" Synthes plates and screws from a small frag set? If we have an implant that comes with a sticker, we put the sticker in an "implant log book," and on the permanent OR record on the chart. I write on the nurses' notes: 1 - 1/3 Tubular plate x 6 holes, and 3.5 cortex screws x 6 (for example). There is no Lot # or Serial # on the plates or screws. The Debate: should the RN write the plate and screws down in the "implant log book," and include the plate and screw numbers, e.g. 305.25? I keep saying the 305 # is a reorder #, NOT a number that means you can track that plate. HELP!!!!!!!

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Rose_Queen is a BSN, MSN, RN and specializes in OR, education.

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Not sure about tracking with the numbers for the plate, but we document in the medical record the numbers of screws and plates, plus the lot number from the autoclave used in SPD. For example, 00109 101 would mean the tray was sterilized Jan 1, 2009, in autoclave 1, in the first load. That way, if any problems were found with the autoclave for any reason, we can track any implants that were in the affected loads to the patient they were implanted into. Obviously, this only works for implants we use, and I'm not sure if Synthes does their own tracking. I know that the reps do write down what was used, but not sure if it's for more than just billing purposes.

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#1rnstudent specializes in orthopaedics, perioperative.

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A lot of our screws come from a bin, and each screw has no identifier number on it so I don't know how we are supposed to track the screws. Plates at our facility have a number in the tray, but I think it is just a reorder number too. We write that one down anyways. Some special screws (lag or compression types, etc.) come packaged separately and they have stickers in the boxes, so that makes life a lot easier. If only we could get away with writing ORIF of (limb goes here) with plate and screws. LOL

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Fun2 is a BSN, RN and specializes in Operating Room.

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Not sure on the brand, but we get numbers from either the box, vendors, or the scrub gives us a number.

More than likely they are reorder numbers, but at least it is documented. We also document the size, site, exp date, manufacturer, etc.

The manufacturer may have more information if ever it was needed.

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GadgetRN71 has 10 years experience as a ASN, RN and specializes in Operating Room.

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We put down reorder numbers and a description of what plate was used in the computer and log book...we don't document the lot number because the trays get refilled by the rep or the staff and there's no way to know which lot any given plate was from.

However, when I document implants in total joint cases, those do have a lot number that easy to find out(because the rep brings the implants case by case) and I document the lot number in the computerized chart.

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shodobe specializes in O.R., ED, M/S.

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Synthes plates have a unique lot number for that particular plate, as far as I can remember. Screws don't so hard to track. Good to document all numbers that correspond to that plate and screws in your implant log. A lot of people don't ask the scrub for these numbers until the plate is implanted and then it's too late.

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NabiRN is a BSN, RN and specializes in OR, community nursing.

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Smith and Nephew has lot #'s on plates but not the screws. I like the idea of keeping track of lot number from autoclave (I don't think we do that now).

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karebear74 has 7 years experience.

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We have those #s on Synthes and S & M they are not tracked implants but we document those 305.XXX #s with a description of the implant..plate etc. Basically it is to cover our butts and later if we need to remove screws etc we have everything about it in our previous documents.

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We are having a similar debate about screws and rods for spinal fusions. Is it necessary to document the lot numbers off the individual screws that are in the implant sets? Our current practice is to try to decipher the lot numbers off each screw, rod, etc. and document it in the chart along with the sterilization load from SPD.

I am not talking about implants that come in a peel packs, I am strictly asking about implants coming from a tray sterilized in our SPD.

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canesdukegirl has 14 years experience as a BSN, RN and specializes in Trauma Surgery, Nursing Management.

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We document much like Poet does. We can trace the plate/screw only from the SPD date. I don't know if the implants can be traced back to the manufacturer this way, but it is something that I will ask my rep when I see him.

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Mr. & Mrs. RN has 9 years experience and specializes in OR.

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Oh yes, we always track our small frag implants. We also track pins and wires that are left implanted. We use the item number (re-order number) as well as a hospital assigned charge number. No lot number is included. We have created our own charge sheet to document charges and it is also entered into the electronic record.

Edited by Mr. & Mrs. RN

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