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INTERNAL ONLY SEALED POLICY COVER SHEET NAME OF DOCUMENTElectronic Intraoperative Nursing Care Record Responsibility and AccountabilityTYPE OF DOCUMENTPolicyDOCUMENT NUMBERSESLHDPD/164DATE OF PUBLICATION

How to fill out electronic intraoperative nursing care

How to fill out electronic intraoperative nursing care:

1. Start by ensuring that you have the necessary electronic form or software for recording intraoperative nursing care. This could be an electronic health record system or a specific software designed for nursing documentation.
2. Gather all relevant patient information, including their medical history, current medications, allergies, and any specific instructions or precautions related to the surgery.
3. Begin documenting the patient's vital signs, including blood pressure, heart rate, temperature, and oxygen saturation levels. Record these measurements accurately and in a timely manner throughout the intraoperative period.
4. Document the patient's surgical procedure details, including the type of surgery, the surgeon's name, and the anticipated duration of the procedure.
5. Continuously monitor the patient's response to anesthesia, including their level of consciousness, respiratory status, and pain level. Update this information regularly and as needed.
6. Document any intraoperative interventions performed by the nursing staff, such as administering medications, managing fluid therapy, or providing wound care.
7. Make sure to record any intraoperative complications or adverse events that occur during the procedure. This could include excessive bleeding, changes in the patient's condition, or equipment malfunctions.
8. After the surgery is completed, ensure that you have documented the patient's post-operative status, including their level of consciousness, vital signs, and any immediate post-operative interventions provided.
9. Finally, review and double-check your documentation for accuracy and completeness before finalizing the electronic intraoperative nursing care record.

Who needs electronic intraoperative nursing care?

Electronic intraoperative nursing care is beneficial for various healthcare professionals involved in the surgical process. This includes:

1. Perioperative nurses: These nurses specialize in providing care to patients before, during, and after surgery. They utilize electronic records to document intraoperative nursing care and communicate vital information to other healthcare team members.
2. Surgeons and anesthesiologists: Electronic intraoperative nursing care records assist surgeons and anesthesiologists in reviewing and understanding crucial details about the patient's condition during surgery. This information can aid in decision-making and ensure patient safety.
3. Other healthcare providers: Intraoperative nursing care records can be accessed by other healthcare providers involved in the patient's care, such as post-operative nurses, wound care specialists, and pharmacists. These records offer valuable insights into the patient's condition during the surgery and help in delivering comprehensive care.

In summary, electronic intraoperative nursing care documentation is essential for accurate and efficient recording of patient information, vital signs, interventions, and complications during surgery. It supports healthcare professionals in delivering safe and effective care while promoting continuity of care across the perioperative period.

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What is electronic intraoperative nursing care?

Electronic intraoperative nursing care refers to the use of electronic systems and technology to record and document nursing care provided to patients during surgery.

Who is required to file electronic intraoperative nursing care?

All nurses and healthcare professionals who are involved in providing intraoperative nursing care are required to file electronic intraoperative nursing care.

How to fill out electronic intraoperative nursing care?

Electronic intraoperative nursing care can be filled out using specific electronic platforms or software provided by healthcare facilities. Nurses need to input detailed information regarding the care provided to patients during surgery.

What is the purpose of electronic intraoperative nursing care?

The purpose of electronic intraoperative nursing care is to accurately document and track the nursing care delivered during surgical procedures. This documentation helps in maintaining patient safety and ensuring quality healthcare outcomes.

What information must be reported on electronic intraoperative nursing care?

Information such as patient demographics, preoperative assessment findings, intraoperative interventions, medications administered, surgical team members, and postoperative care details must be reported on electronic intraoperative nursing care.