Patient Records and Care Documentation

Guidelines:

• The perioperative nurse maintains accurate patient records/documentation of all care provided
• Documentation per healthcare organization policy and state/federal regulatory and accreditation requirements
• Complete, accurate, timely

Considerations:

• Healthcare records should maintain a complete, comprehensive, and accurate description of concurrent, ongoing, and transitional perioperative care
• The operative record is a permanent part of the patient’s medical record
• Nearly all components of perioperative clinical documentation relate directly or indirectly to patient safety and injury prevention.

Nurse’s role:

• Proper use of documentation tools
  • EHR, downtime forms, implant records, incident/adverse events reporting
• Documentation of operative information
  • Preoperative diagnosis
  • Surgical procedure performed
  • Description of findings
  • Specimens removed
  • Postoperative diagnosis
  • Persons present
• Documentation of nursing care
  • ESU # and settings
  • Medications
  • Evidence of ongoing assessment
  • Interventions
• Documentation of universal protocol safety measures
  • Pre-procedural briefing, site marking, informed consent, time-out, debriefing
• Documentation of transfer of care
• Maintain patient privacy
  • (HIPAA)

Pitfalls:

• Confusion and contradiction in the operative record enhances the likelihood of a successful lawsuit by demonstrating that team members involved were not acting as reasonable and prudent caregivers.
  • Ensure documentation is complete, accurate
  • Objective information only in documentation
  • Include in relief/hand-off communication

Examples:

• Missing/Inaccurate documentation after accepting handover during a permanent shift relief in an OR

Linchpins (Key Points):

• Perioperative nurses are responsible for accurate, complete, and timely documentation of perioperative patient care and activities
• Follow healthcare organization policy for documentation requirements
• Maintain patient privacy
• Team Communication