Perioperative HealthCare Information Management Flashcards
Standards of nursing practice require that documentation is based on the
Patient’s condition or needs
Relationship of condition or need to the proposed intervention
Requirements for documenting the electrical equipment used:
Location of dispersive electrode pad, reference number, settings
Any skin abnormalities or need for hair removal at the placement site for pad
Placement/location of compression stockings and SCD’s.
Requirements for documenting temperature regulating devices
Use of any warming or cooling blankets
Location of the blanket
ID number of the unit and the temperature setting
Patient’s temp before/after discharge from the surgical suite
Requirements for documenting laser use
Type of laser
Procedure and laser operator
ID number
Power settings (wattage) and length of time used
Safety measures implemented
Requirements for documenting Pneumatic/electrical tourniquet use
Skin protection/padding used
ID of person who applied the tourniquet
ID/serial number and model of the specific tourniquet
Location of cuff placement
Cuff pressure
Inflation/Deflation times
Requirements for documenting skin antisepsis
Skin condition
Hair removal
Area prepped
Solutions used
Person performing the prep
Any hypersensitivity reactions
3 steps identified by TJC to prevent errors
The correct surgery is done on the correct patient and done at the correct location on the patient’s body
The correct location is marked where surgery is to be done
A time out is conducted before surgery to prevent a mistake
Requirements for documenting implants
Manufacturer
Lot/Serial numbers
Type or name
Size of implant, if applicable
Expiration date
Placement and location of implants
Documenting tubes and drains
Type of tubes inserted (foley catheter, penrose drain)
Type of packing that is inserted
Size and length
Placement location on the patient
Wound class I
Clean wound (Not infected or inflamed)
Wound is a result of non-penetrating, blunt trauma
Respiratory/alimentary/genitourinary tracts were not entered
Hernia repairs, breast surgery, thyroidectomy
Wound class II
Clean-contaminated wounds
No major break in surgical technique (spillage from GI tract)
Respiratory/alimentary/genitourinary tracts were entered under controlled conditions and without evidence of infection or contamination
C-section w/wo ruptured membranes or long labor
D&C
Total abdominal hysterectomy
Tonsillectomy
Wound class III
Contaminated wounds
Open, fresh, traumatic (accidental) wounds
Major breaks in sterile technique (unsterile instruments used during procedure)
Entrance into the genitourinary or biliary tracts with infection
Gross spillage from the GI tract
Incisions in which acute, nonpurlent inflammation is encountered
C- section with meconium
Pilonidal cyst with acute inflammation
Wound class IIII
Retained devitalized tissue (gangrene, necrosis)
Wounds that involve existing clinical infection or perforated viscera
Old traumatic wounds with retained devitalized tissue
This classification suggests infectious process was present before surgery
Purulent clinical infection
Systemic infections
Documenting airway status/mental state
Type and presence of an airway
Oxygen flow rate in liters per minute when the patient is transported with oxygen
Patient’s mental state of alertness, drowsiness or somnolence (sleep) is noted just prior to discharge from the surgical suite and again immediately on arrival in the PACU
Elements of a successful lawsuit
Duty (you owed the patient a duty to provide care within acceptable standards of practice)
Breach of duty (you breached your duty to provide adequate care for your patient)
Causation (your failure to provide standard care caused the patient’s injury)
Damages (your patient actually suffered an injury)
