Session 2 - OR Slate *wink wink nudge nudge* Flashcards
What are some surgical chart forms?
- Surgical consent form
- Pre-op checklist / OR check off list
- Anesthetic record
- Surgical count sheet / OR count sheet
- Perioperative nursing record
- Physicians operation report (followed by transcribed report)
- Post anesthetic recover room (PACU) record
Surgical consent form
The patient must sign a consent to surgical/investigative procedure authorizing the surgeon to carry out the surgical/investigative procedure
Pre-op checklist / OR check off list
The checklist is completed by the RN to ensure all pre-operative tests and procedures have been done and the patient is prepared and ready for surgery
Anesthetic record
Used by the Anesthetist to record their observations and record all medications given to the patient during surgery
Surgical count sheet / OR count sheet
Record all instruments used during a surgical procedure and account for all instruments following the surgery. The form is completed by the operating room nurse
Perioperative nursing record
Used by the OR nurse to record all information relevant to the surgical procedure, before, during, and after the procedure is completed
Physicians operation report
Report detailing all aspects of the surgical procedure from start to finish, who was involved, findings, etc.
Post anesthetic recovery room (PACU) record
The PARR RN will record all observations, medications given, and progress of the patient in the recovery room
List some Misc OR reports
- Post-Surgical Ward Assessment
- Fluid Balance Record
- Surgical Pathology Report
- Blood Transfusion Consent
- Refusal for Blood Transfusion
- Blood Administration Record
Post-Surgical Ward Assessment
Completed by the RN when the patient returns to the nursing unit post-op from the recovery room. They record all patient vitals and observations
Fluid Balance Record
Record used by the RN for monitoring all patient fluid intake and outputs during their surgical procedure and hospital stay
Surgical Pathology Report
A report detailing specimen collected information that may have been removed from the patient during surgery and requires Pathological investigations
Blood Transfusion Consent
Consent signed by the patient to allow transfusion of blood and/or blood products if it becomes necessary during the course of the patient’s treatment
Refusal for Blood Transfusion
Form signed by the patient refusing the administration of blood and/or blood products during the course of their treatment
Blood Administration Record
Record used to record all blood/blood products administered given during the patient’s surgical procedure or hospital visit
