Implant Records and Tracking for Certified Perioperative Nurse (CNOR)
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Outline
Implant Records and Tracking
Guidelines:
- United States Food and Drug Association (FDA) requires strict guidelines in properly documenting and tracking implants
- Documentation should included in, but not limited to:
- Patient’s permanent record
- Patient’s operative record
- Implant registry maintained by the OR
- Implant registry includes:
- Lot #
- Serial #
- Manufacturer
- Size
- Type
- Anatomic position of implant
Considerations:
- Implants may be medical devices, tissue, or tissue products
- Allografts
- Xenografts
Nurse’s role:
- Perioperative nurses are responsible for:
- Complying with tracking regulations for implantable materials and devices
- Follow institutional policy for implant tracking and documentation requirements
- Document complete implant information in the OR documentation
- Promote patient safety and privacy
Pitfalls:
- Incomplete documentation of implants can endanger the patient
- Policies and procedures for required implant documentation and logging may not be the same at other healthcare organizations
Examples:
- N/A
Linchpins (Key Points):
- FDA: requires implants to be documented and tracked
- Healthcare organization: creates policies and procedures for documentation and tracking
- Manufacturer: provides and tracks implants
- Perioperative RN: complies with tracking regulations and documentation policies for implantable material and devices
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Transcript
References
- Rothrock, J. (2019). Alexander’s Care of the Patient in Surgery (16th ed.). Elsevier Health Sciences.
- Association of perioperative Registered Nurses (AORN): Guideline Essentials (website), 2022, https://www.aorn.org/guidelines-resources/guidelines-for-perioperative-practice/guideline-essentials
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Certified Perioperative Nurse (CNOR)
Course Lessons
Perioperative Patient Assessment and Diagnosis
Confirming Patient Identity (Patient Identifiers) for Certified Perioperative Nurse (CNOR)
Confirmation of Correct Procedure (Operative Site, Side, Site Marking) for Certified Perioperative Nurse (CNOR)
Relevant Patient Data Review for Certified Perioperative Nurse (CNOR)
Age and Culturally Appropriate Health Assessment Techniques for Certified Perioperative Nurse (CNOR)
Medication Reconciliation Review for Certified Perioperative Nurse (CNOR)
Individualized Physical Assessments for Certified Perioperative Nurse (CNOR)
Procedurally-Relevant Focused Assessments for Certified Perioperative Nurse (CNOR)
Pain Assessments for Certified Perioperative Nurse (CNOR)
Formulating Nursing Diagnoses for Certified Perioperative Nurse (CNOR)
Advanced Directive and DNR Status Confirmation for Certified Perioperative Nurse (CNOR)
Patient and Family Teaching (Per Procedure) for Certified Perioperative Nurse (CNOR)
Plan of Care
Identifying Measurable Patient Outcomes for Certified Perioperative Nurse (CNOR)
Identifying Interventions per Nursing Diagnoses for Certified Perioperative Nurse (CNOR)
Care Plan Review (Addresses Patient Considerations) for Certified Perioperative Nurse (CNOR)
Evaluating Patient Response to Plan of Care for Certified Perioperative Nurse (CNOR)
Plan of Care Updates for Certified Perioperative Nurse (CNOR)
Critical Thinking to Facilitate Patient Care for Certified Perioperative Nurse (CNOR)
Intraoperative Care
Comfort Provisions (Behavioral Response to Procedure) for Certified Perioperative Nurse (CNOR)
Pharmacological Patient Response Evaluation for Certified Perioperative Nurse (CNOR)
Anesthesia Management Assistance for Certified Perioperative Nurse (CNOR)
Blood Salvage Transfusion Anticipation for Certified Perioperative Nurse (CNOR)
Body Mechanics (Utilization) for Certified Perioperative Nurse (CNOR)
Room Preparation (Equipment, Supplies, Personnel) for Certified Perioperative Nurse (CNOR)
Product Assessment (Packaging, Sterilization) for Certified Perioperative Nurse (CNOR)
Cost Containment Measures for Certified Perioperative Nurse (CNOR)
Product Evaluation and Selection for Certified Perioperative Nurse (CNOR)
Healthcare Team Member Supervision and Education for Certified Perioperative Nurse (CNOR)
Delegation and Personnel Management for Certified Perioperative Nurse (CNOR)
Visitor Supervision for Certified Perioperative Nurse (CNOR)
HCIR Management (Healthcare Industry Representative) for Certified Perioperative Nurse (CNOR)
Patient Positioning (Performance) for Certified Perioperative Nurse (CNOR)
Communication and Documentation
Implant Preparation for Certified Perioperative Nurse (CNOR)
Explant Preparation (Final Disposition) for Certified Perioperative Nurse (CNOR)
Labeling (Medications, Solutions, Containers) for Certified Perioperative Nurse (CNOR)
Conflict Management (Patient, Perioperative Team, Family) for Certified Perioperative Nurse (CNOR)
Patient Records and Care Documentation for Certified Perioperative Nurse (CNOR)
Interdisciplinary Healthcare Team Collaboration for Certified Perioperative Nurse (CNOR)
Patient Status Communication for Certified Perioperative Nurse (CNOR)
Communication of Patient Outcomes (Continuum of Care) for Certified Perioperative Nurse (CNOR)
Perioperative Education Documentation for Certified Perioperative Nurse (CNOR)
Postoperative Follow-up for Certified Perioperative Nurse (CNOR)
Perioperative Assessment Documentation for Certified Perioperative Nurse (CNOR)
Transfer of Care Documentation for Certified Perioperative Nurse (CNOR)
Implant Records and Tracking for Certified Perioperative Nurse (CNOR)
Patient Status Evaluation (Transfer of Care) for Certified Perioperative Nurse (CNOR)
Patient Communication Techniques for Certified Perioperative Nurse (CNOR)
Patient Confidentiality for Certified Perioperative Nurse (CNOR)
Verbal Order Read-Back for Certified Perioperative Nurse (CNOR)
Surgical Wound Classification Documentation for Certified Perioperative Nurse (CNOR)
Specimen Prep, Tracking, and Transporting for Certified Perioperative Nurse (CNOR)
Implant Verification and Availability for Certified Perioperative Nurse (CNOR)
Infection Prevention and Control
Surgical Site Preparation for Certified Perioperative Nurse (CNOR)
Barrier Material Selection (Procedure-Specific) for Certified Perioperative Nurse (CNOR)
Environmental Factor Control for Certified Perioperative Nurse (CNOR)
Sterile Field Maintenance (Aseptic Technique) for Certified Perioperative Nurse (CNOR)
Equipment Utilization (Manufacturers Recommendations) for Certified Perioperative Nurse (CNOR)
Wound Dressing Maintenance for Certified Perioperative Nurse (CNOR)
Environmental Cleaning (Spills, Room Turnover, Terminal Cleaning) for Certified Perioperative Nurse (CNOR)
Sterilization and Cleaning (Instruments, Reusable Goods) for Certified Perioperative Nurse (CNOR)
Transportation and Storage (Single Use Items) for Certified Perioperative Nurse (CNOR)
Sterilization and Disinfection Documentation for Certified Perioperative Nurse (CNOR)
Hazardous Material Handling and Disposition (Chemo, Radioactive) for Certified Perioperative Nurse (CNOR)
Biohazard Material Handling and Disposition (Blood, Microbiology, Creutzfeldt-Jakob Disease) for Certified Perioperative Nurse (CNOR)
PPE Precautions (Personal Protective Equipment) for Certified Perioperative Nurse (CNOR)
Sterilization, Biological, Chemical Monitoring and Documentation for Certified Perioperative Nurse (CNOR)
Sterilization and Storage Environment Conditions for Certified Perioperative Nurse (CNOR)
Outside Instrument and Material Tracking (Regulatory Requirements) for Certified Perioperative Nurse (CNOR)
Surgical Attire Guideline Adherence (Surgical, Perioperative Zones) for Certified Perioperative Nurse (CNOR)
Hand Hygiene Guideline Adherence for Certified Perioperative Nurse (CNOR)
Wound Classification for Certified Perioperative Nurse (CNOR)
Retained Surgical Items for Certified Perioperative Nurse (CNOR)
Emergency Situations
Patient and Personal Safety (Environmental Hazard Monitoring) for Certified Perioperative Nurse (CNOR)
Emergency Situation Identification for Certified Perioperative Nurse (CNOR)
Malignant Hyperthermia (MH) Nursing Interventions for Certified Perioperative Nurse (CNOR)
Anaphylaxis Nursing Interventions for Certified Perioperative Nurse (CNOR)
Cardiac Arrest Nursing Interventions for Certified Perioperative Nurse (CNOR)
Trauma Nursing Interventions for Certified Perioperative Nurse (CNOR)
Hemorrhage Nursing Interventions for Certified Perioperative Nurse (CNOR)
Local Anesthetic Systemic Toxicity (LAST) Nursing Interventions for Certified Perioperative Nurse (CNOR)
Interdisciplinary Team Member Functions for Certified Perioperative Nurse (CNOR)
Patient and Healthcare Team Safety (Disasters, Environmental Hazards) for Certified Perioperative Nurse (CNOR)
Positioning (Pressure Injury Prevention and Tourniquet Safety) for Certified Perioperative Nurse (CNOR)
Professional Accountability
Patient Privacy and Dignity Maintenance for Certified Perioperative Nurse (CNOR)
Patient Rights Advocacy for Certified Perioperative Nurse (CNOR)
Surgical Counts for Certified Perioperative Nurse (CNOR)
Universal Protocol Performance for Certified Perioperative Nurse (CNOR)
Environmental Stewardship (Waste Minimization) for Certified Perioperative Nurse (CNOR)
Function Within Scope of Practice for Certified Perioperative Nurse (CNOR)
Accountability and Assistance for Personal Limitations for Certified Perioperative Nurse (CNOR)
Impaired or Disruptive Behavior Reporting (Interdisciplinary Healthcare Team) for Certified Perioperative Nurse (CNOR)
Ethical and Professional Standards for Certified Perioperative Nurse (CNOR)
Personal Growth Resources for Certified Perioperative Nurse (CNOR)
Quality Improvement Participation for Certified Perioperative Nurse (CNOR)
Interdisciplinary Team Participation for Certified Perioperative Nurse (CNOR)
Professional Organization Participation for Certified Perioperative Nurse (CNOR)
