counts in the OR

[elleRN]

What does your facility do in terms of paperwork used when doing a c section. We have a worksheet that lists all the instruments etc. that we use while counting, once the section is done, we check off the boxes on the actual c section record for the pt that all counts are correct for instruments, sponges etc, and both the circulating nurse and scrub nurse or tech sign this. it doesn't give a detailed list like the worksheet does though. once the or record is filled out the worksheet just goes in the garbage. it is not considered part of the pt's record. one of the nurses mentioned to me that it should stay in the record because it is better to have in case a lawsuit happens. should i keep these papers rather than thow them out so i cover my self?? what do you guys use??? thanks!!!

[DIPLOMATICRN4HIRE, MSN, RN]

We use computer charting and initals are put in but the circulator only signs the charting that the counts were either correct or incorrect. On the computer charting it does have 3 places for the intials to be placed of the scrub and circulator. First count, second and final counts. Once you have that your covered.

When we had handwritten charts , both the scrub and circulator signed the count sheets. I always tossed the instrument count sheet simply because it was just a sheet that listed the instrument names and the amount of each instrument. That isnt needed. You know what a basic pack has in a c section you can recall it off the top of your head. The chart itself is the only counts that have needles,sponges,laps,and instrument counts with the area that states was count completed, signature. Other than that its all you need. The paper in the cracked case is not needed. Even for a court of law.

Zoe