Occurence Reports

I have been advised that you chart that which you "invasively" do to the patient. In the instance of the armboard, if there is no apparent injury to the extremity, an incident report would suffice. This would then be available for later issues of concern. In the event of a bovie burn, you would need to chart in your nursing notes something to the effect of "incidental burn to arm... " Document presence of redness, blistering, or whatever and size of area noted. Document any treatment to area. Laws have been passed that indicate that all patients are to be informed of any significant occurrences/errors that may result in untoward outcomes. Your hospital attorney and risk manager may have specific verbage recommended for use. They would much rather be notified sooner than later when events occur. Error on the side of being quick to report any concerns.

Chart to the record. If you have a place for "integrity of the bovie site" and you have a less than uneventful site at the end of the case, either a rash, or a burn it needs to be addressed on that record. An incident report ALWAYS needs to be filled out. If a pt. undergoes any untoward event during the surgery then the pt. care plan automatically shifts and needs to be documented on the intraoperative record where indicated.