TITLE: GUIDELINES FOR USE OF THE INTRAOPERATIVE RECORD NURSE'S NOTES (MR #848)

INSTRUCTIONS:

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1. Label the space provided on all three (3) copies with the patient’s sticker. Verify that you have the correct patient labels.
2. ATTENDING SURGEON(S): Include all attending surgeons for the procedure(s)
3. DATE: Write in the current date
4. O.R. #: Write in the operating room number where the surgery is occurring
5. RESIDENT SURGEON(S): Include all surgical residents present for the procedure(s)
6. PT. FLOOR: Write in the patient’s room number or transferring unit if inpatient.  Write ‘OPS’ if the patient is an outpatient or ‘AMS’ if the patient is to be admitted after surgery
7. 2E     ODS: Check the appropriate box signifying where the surgery is occurring
8. ATTENDING ANESTHESIOLOGIST(S): Include all attending anethesiologists for the procedure(s)
9. RESIDENT ANESTHESIOLOGIST(S): Include all resident anesthesiologists present for the procedure(s).  If none present write ‘N/A’.
10. CRNA(S): Include all CRNAs present for the procedure(s).  If none present write ‘N/A’.
11. PREOP ASSESSMENT:

·         PT. IDENTIFICATION: All patients are to be identified by their name and date of birth (DOB).  If the patient is unable to verbally verify identification, the nurse shall verify the name and DOB on the patient’s armband with the Patient Information Sheet or the Patient Care Summary.

Place a check next to any of the remaining identification choices that are used to verify the patient’s identification.

·         ALLERGIES: List all of the patient’s allergies. If additional space is needed write ‘see comments’ and write the remaining allergies on the second page under ‘Comments/Medications’.  If the patient has no allergies check the box next to ‘none’.

·         VERIFICATION OF PROCEDURE/LOCATION: Place a check in the box next to all applicable methods used to verify the procedure(s) and location(s).

·         TRANSFUSION: Check if a transfusion consent is signed or if a transfusion refusal is signed.

·         LIMITATIONS: Place a check in the appropriate box if any of the listed limitations are present. NOTE: If the patient has an implant/prosthesis, document type/laterality on the line underneath that choice.

·         RN SIGNATURE: The RN who completes this assessment process signs

·         OUTCOME: Check either yes or no that the stated outcome was met.

·         RN INITIALS: The RN who determines if the outcome was met initials here

12. PLAN AND IMPLEMENTATION: Check the box next to each descriptive that applies.  If other measures were utilized, check the box for ‘other’ and write in those measures.
13. OUTCOME: Check either yes or no that the stated outcome was met.
14. RN INITIALS: The RN who determines if the outcome was met initials here
15. TIME OUT (Procedure and Site Verified): Prior to the incision or the beginning of the procedure, the surgeon, anesthesiologist, circulator, and scrub person verify that the right patient is in the room, the procedure, and the site.  The names of these persons are documented in the labeled spaces. Include the scrub person’s name with the circulator’s name. (NOTE: There will be a space provided for the scrub person’s name with the next printing of the form.)
16. POSITION/PROCEDURE CHANGE: Place a check in the ‘yes’ box if there is a change in the position or procedure.  If yes, write on the line provided what change(s) was made. Check the ‘no’ box if there is no change. Document the names of the surgeon, anesthesiologist, circulator, and scrub person who completed the time out for the change.  (NOTE: There will be a space provided for this information with the next printing of the form.)
17. ARRIVAL: The time (military) the patient enters the operating room
18. TURN OVER TO SURGEON: The time (military) that the anesthesiologist turns the patient over to the surgeon to begin the positioning, surgical prep and/or foley placement.
19. START: The time (military) that the incision is made or the procedure is started.  Two (2) areas are provided so that the start time of a second surgical service is documented.
20. SERVICE: Document the surgical service next to the corresponding start time.
21. FINISH: The time (military) that the dressing is applied or the procedure is completed.  Two (2) areas are provided so that the finish time of a second surgical service is documented.
22. DEPARTURE: The time (military) the patient exits the operating room.
23. SURGERY: Check one box utilizing the following definitions. NOTE: The definitions are listed on the back of the intraoperative record.
    • Elective: Case posted through the scheduling office.
    • Emergent: Procedure must be done immediately to prevent loss of function, limb, or life.  If there is not an open room a scheduled procedure must be “bumped” in order to accommodate the emergency.
    • Urgent: Procedure must be done within 8 – 24 hours to prevent loss of function, limb, or life.  The procedure can be performed when the first available room is open.
    • Add-on: An add-on procedure is one that is added to the posted elective schedule and will be done if/when time and personnel are available.

The coordinator can assist the nurse in determining the appropriate category if necessary.

24. ANESTHESIA TYPE: Place a check next to the type of anesthesia the patient receives.  NOTE: If the patient initially receives either a local or regional anesthetic and then requires a general anesthetic, indicate by checking all appropriate boxes.  In the comment section on the second page document the type of anesthetic the patient received initially and the reason(s) for administering a general anesthetic.
25. LOCAL AGENT: If applicable, document the type and strength of the local anesthetic given, the name and title of the person administering the local agent, and the total number of cc’s given.
26. PREOP DIAGNOSIS: Document the preoperative diagnosis that is listed on the operative consent and/or the history and physical.
27. POSTOP DIAGNOSIS: Document the postoperative diagnosis provided by the surgeon.  If the postop diagnosis is the same as the preop diagnosis, the nurse may document “same as preop”. NOTE: If the preop diagnosis includes “possible……” do not write “same as preop” for the postop diagnosis. 
28. OPERATIVE PROCEDURE: Document the procedure as dictated by the surgeon
29. COMPLICATIONS: Check the applicable box. If there were complications, document the facts in the comment section on the second page.
30. PROCEDURE CANCELED: If the procedure was not canceled check the box for ‘N/A’.  If the procedure was canceled after the patient entered the O.R., check the box for either ‘before induction’ or ‘after induction’ based on the patient’s status. 
31. SPECIMEN TYPES:
    • P = Permanent    Specimen is placed in formalin.
    • FZ = Frozen Section    Specimen is sent fresh to Pathology for frozen section.
    • FH = Fresh Permanent     Specimen is sent without fixative to Pathology.
    • B = Bacteriology    Specimen is sent to the clinical lab.
    • C = Cytology   Specimen is delivered the Cytology lab.

When a specimen is obtained, document the code for the type of specimen in the column labeled ‘type’. In the ‘specimen’ column document the name of the specimen. The nurse who processes the specimen writes his/her initials in the labeled column.

32. X-RAY: If the patient is x-rayed in the OR check yes and document the type of x-ray, e.g. c-arm, portable for line placement, etc. Check ‘no’ if no x-rays were taken in the O.R.
33. BLOOD TRANSFUSION: Check yes or no indicating if the patient received blood in the O.R..  Indicate yes or no if  the patient had a blood transfusion reaction.  Indicate by checking if the cell saver was used during the procedure.
34. ARREST: Check yes or no if the patient arrested in the O.R.  If yes, document the time of the arrest, time CPR initiated, person performing CPR.  If defibrillated, document time, watts/second, internal or external paddles used, who defibrillated the patient.
35. OUTCOME: Check either yes or no that the stated outcome was met.
36. RN INITIALS: The RN who determines if the outcome was met initials here.
37. SCRUB PERSONNEL: Document all O.R. scrub personnel, including scrub tech students & orientees.  Document in and out times for each person.  NOTE:  There are 3 sets of in/out times for each person to accommodate breaks during lengthy procedures.
38. CIRCULATING NURSES: Document all OR circulators including orientees.  Document in and out times for each person.  NOTE:  There are 3 sets of in/out times for each person to accommodate breaks during lengthy procedures.
39. RELIEF REPORT GIVEN BY & RECEIVED BY:  The nurse who is being relieved at the end of the shift or who is being assigned to another duty gives the incoming nurse a full report.  Each nurse signs the appropriate space on the record.  NOTE: There are two (2) sections for documenting reports to accommodate assignment changes or shift changes.  (Not for break or lunch relief changes.)
40. VENDORS/OBSERVERS PRESENT: Document all persons who are present but are not listed separately on the record, e.g. healthcare students, vendors, visiting surgeons, etc. If no observers are present, write “N/A” on the line.
41. LASER SAFETY OFFICER/APPROVED LASER OPERATOR: Document the name of the approved person(s) who is present to operate the laser.  If there is not a laser operator, write “N/A” on the line.
42. CELL SAVER OPERATOR: Document the name of the person who is responsible for and who is operating the cell saver.  Place a check for N/A if there is no cell saver.
43. PERFUSIONIST: Document the name of the perfusionist.  Place a check for N/A if there is no perfusionist.

RESOURCE PERSON(S):  Sharon Schneider, BSN, RN, CNOR

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