Get the free Medical record intraoperative document da form 5179-1, oct 87 - whs

Changes in force: C 2 AR 600-87. *C 2 PERSONNEL-GENERAL ADVANCE NOTICE FOR PERSONNEL VISITING FOREIGN COUNTRIES CHANGE HEADQUARTERS DEPARTMENT OF THE ARMY No. Sf WASHINGTON, B.C., 4 February 1964

How to fill out medical record intraoperative document

How to fill out a medical record intraoperative document:

1. Start by filling out the patient's personal information, including their name, age, gender, and contact information.
2. Next, document the date and time of the surgery, as well as the name of the surgeon and any assistants or medical staff involved.
3. Provide a brief medical history of the patient, including any pre-existing conditions, allergies, or medications they are currently taking.
4. Record the reason for the surgery and any relevant diagnosis or findings. This should include any imaging or lab results that influenced the decision for surgery.
5. Document the type of anesthesia used and the medications or agents administered during the procedure.
6. Record the procedure itself, including the specific steps taken, techniques used, and any complications or unforeseen events that occurred during surgery.
7. Note any specimens or samples obtained during the surgery, such as tissue for biopsy or cultures for testing.
8. Document any additional procedures or interventions performed during the surgery, such as the insertion of drains or catheters.
9. Record the postoperative instructions given to the patient, including any medications prescribed, follow-up appointments, and restrictions or limitations to their activities.
10. Finally, ensure that the document is signed and dated by the surgeon and any other relevant medical staff involved in the surgery.

Who needs a medical record intraoperative document?

1. Surgeons and surgical teams: The medical record intraoperative document serves as an important legal and medical record of the surgery. Surgeons and their teams need this document to accurately document the procedure and communicate important information to other healthcare providers.
2. Anesthesiologists: Since the document includes information about the type of anesthesia administered, anesthesiologists can use it to ensure continuity of care and provide accurate reports for future reference.
3. Postoperative care team: The postoperative care team, including nurses, nurse practitioners, and physician assistants, may review the document to monitor the patient's progress and make informed decisions about their ongoing care.
4. Medical researchers and educators: Intraoperative documents can be valuable resources for medical research and education purposes. They provide detailed information about surgical techniques, outcomes, and complications that can contribute to improving patient care and advancing medical knowledge.

For pdfFiller’s FAQs

What is medical record intraoperative document?

Medical record intraoperative document is a detailed report of a patient's condition and treatment during a surgical procedure.

Who is required to file medical record intraoperative document?

The healthcare provider or surgeon who performed the procedure is required to file the medical record intraoperative document.

How to fill out medical record intraoperative document?

The document should be filled out accurately and completely, documenting all relevant information regarding the surgery and the patient's condition.

What is the purpose of medical record intraoperative document?

The purpose of the document is to provide a comprehensive record of the surgical procedure, including details of the surgery, anesthesia, and any complications that may have occurred.

What information must be reported on medical record intraoperative document?

The document should include details of the procedure performed, anesthesia used, vital signs, any complications, medications administered, and the patient's response to treatment.

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