A follow up question to the discussion of this thread in the operating room nurses' forum:
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!!
May 31, '07
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.
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.
Last edit by CarVsTree on May 31, '07
: Reason: What I Look for: