Get the free paper perioperative documentation record form - nursing uchc

Clinical Procedure JDH Perioperative Unit Practice Manuals John Dempsey Hospital-Department of Nursing PROCEDURE FOR Page 1 of 4 Documentation Perioperative Electronic and Paper Back-up POLICY 1. The RN is responsible for documentation of all nursing care pre- intra- and postoperatively. Prior to beginning documentation it is the first responsibility of the nurse to assure that s/he has opened the correct record for the patient about whom they intend to document. A copy of the handwritten...

How to fill out paper perioperative documentation record

How to fill out a paper perioperative documentation record:

1. Start by accurately recording the patient's demographics, including their name, age, gender, and contact information.
2. Document the patient's medical history and any preexisting conditions that may impact the surgical procedure.
3. Clearly state the reason for the surgery and indicate the surgical procedure that will be performed.
4. Include details about the anesthesia that will be administered during the procedure.
5. Record any preoperative medications and allergies that the patient may have.
6. Document the vital signs, such as blood pressure, pulse rate, and temperature, before and after the surgery.
7. Note any complications or unexpected events that occurred during the procedure.
8. Include all postoperative instructions, such as medication prescriptions, activity restrictions, and follow-up appointments.

Who needs a paper perioperative documentation record:

1. Surgeons rely on the documentation record to keep a detailed account of the procedure performed and any complications that arise.
2. Anesthesiologists use the documentation record to record the type and amount of anesthesia administered, as well as any patient reactions or adverse events.
3. Nurses and other healthcare professionals involved in the patient's care use the documentation record to ensure continuity of care and to monitor the patient's progress.
4. Medical administrators and quality assurance personnel may also require the documentation record for auditing purposes and to ensure adherence to established protocols and standards.

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What is paper perioperative documentation record?

Paper perioperative documentation record is a physical document that is used to record detailed information about a patient's surgical procedure and anesthesia management before, during, and after the surgery.

Who is required to file paper perioperative documentation record?

The surgical team, including the surgeon, anesthesiologist, and nurses, is responsible for completing and filing the paper perioperative documentation record.

How to fill out paper perioperative documentation record?

To fill out the paper perioperative documentation record, the surgical team should provide accurate and detailed information about the patient's medical history, surgical procedure, anesthesia management, any complications encountered, and post-operative care.

What is the purpose of paper perioperative documentation record?

The purpose of the paper perioperative documentation record is to ensure comprehensive documentation of the surgical procedure, anesthesia management, and patient care. It serves as a legal record, aids in quality assessment, and provides a reference for future medical treatments.

What information must be reported on paper perioperative documentation record?

The paper perioperative documentation record should include information such as patient demographics, medical history, surgical details, anesthesia techniques used, intraoperative monitoring, medications administered, complications, and post-operative care instructions.