Surginet Documentation

Hello All,

I had a question about our Surginet Documentation. My first and most important question is when I hit finalize in the Surginet Nursing OR document am I allowed to go back in at a later time and alter it without being penalized? I have asked numerous staff members at my hospital and no one can give me a straight answer. I have also asked to speak with the Clinical Nurse Educator about it on Monday but I really want to know the guidelines about this particular issue because it gives me much anxiety when charting and I cannot find a policy anywhere. I have done this currently because I was told that it was okay by a coworker and I felt the document really needed to reflect the procedure that we did, but then what is the point of having the finalization button there if it can just be modified at any time?

The reason that I am asking is due to surgeons changing their pre/postoperative medical diagnoses and surgical procedures. I often have to chase surgeons down to make them sign out with me after the procedure and often times they give me minimal surgical procedural information which often leaves me with having to hunt down their operative notes to recorrect and document the appropriate information in the chart. I feel this is not the appropriate practice and I want to know what others are doing and if anyone else is having similar situations as this. I am just trying to document the most correct information on my patients and this struggle is really making me uneasy as I know this is a legal document.

My second question is a little bit more of a general question but still has to do with the charting and is about the medications that I order from Pharmacy. So I order the medication under my surgeon's name but I am the one dispensing it to the field, so should the MAR indicate my name when documenting the administration or my surgeon's? I have also been told that either myself or the surgeon would suffice, but considering I did not order it I feel that it should be the surgeon's name rather than mine.

I am still learning everyday in this specialty, so I just want to be safe and legally correct for both my patients and myself. Again, I am going to speak to the CNE on Monday to try to dig up further clarification. Any feedback would be helpful!