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Most of our OR record consists of blocks to check, and blank lines for fill in the blank kind of info, like tourniquet pressure, time up and down, etc.
When we don't use it, like our Cellsaver, etc, I and the rest of the nurses mark n/a or put some sort of slash through it.
This way it doesn't look like an error of omission.
Lanks
2 Posts
When filling out the nursing record if a given area ie cautery or tourniquet is not used, what do other facilities do. Do you leave it blank, rationalizing if it wasn't charted, it wasn't done. Or do you put a line through it to show its not applicable? Or are there other methods?