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Operating room documentation

Last post 05-17-2012, 2:17 PM by KMalone. 1 replies.
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  •  04-06-2012, 10:43 AM 9743

    Operating room documentation

    I am currently doing a process improvement project in the operating room around inventory management and documentation. Does anyone have any information as to which items and which steps need to be charted throughout a surgical procedure? More specifically which items need to be charted in an Operating Room Information System. I have been researching but have not found any standard published documents. 

    Thank you,


  •  05-17-2012, 2:17 PM 9757 in reply to 9743

    Re: Operating room documentation

    Your question could lead to a long list of detailed data element that cover   pre-operative, anesthesia, intra-operative and post-operative care.

    In broad terms the documentation will need to include  patient verification steps taken, patient assessment data including anesthesia assessments, anesthesia plans, allergies, medications and planned procedure  and preoperative preparation.   Intraoperatively in is important to capture all time elements, patietn verifications,   the nursing plan of care, all patient positioning and preparations.   The sponge, needle and instrument counts are documented.  Any drains and or implants are documented.  Medications are noted.   A post-op nursing assessment should be included.

    For Recovery vital signs and patient assessments are noted.   Times are also important.   Patient/family teaching is documented and  a fuctional score at admission and discharge should be included in the record.

    The best source for details required is in Association of Operating Room Nurse (AORN) literature.






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