Intraoperative Documentation

[cbrouk9199]

I have a nurse who is refusing to document the diagnosis and procedure on the nursing operative report without a reason as to why she has too. I have never had this come up before. To me it is the nurses way to document what was done and why. I have tried to find specific documentation as to why thru AORN but haven't found what I am looking for.

Thank you!!

[Rose_Queen, BSN, MSN, RN]

Refer the nurse to the policy. If he/she refuses to follow the policy, then discipline as necessary. I truly doubt you will find any kind of articles for evidence as this is likely something pretty much left to facilities to determine via policy.

I have to double document a fair amount of what the surgeon also documents (diagnosis, procedure, wound class) because of reports that are run for statistical data. Much easier for the number crunchers to find it in a single report than to have to go to multiple places in the chart. Whether I agree with that is another topic, but I follow the policy to keep my gluteus covered.