Documentation of Equipment use

Documentation of Equipment use

posted by Cherie Clemmons on Nov 2, 2016 10:26 am

Does anyone else document in the patient record the  identification numbers of the bovie used?  I would also like to know if so what other equipment numbers are documented ie. (bovie pad, SCD machine, Heart Lung machine). 

Re: Documentation of Equipment use

posted by Emily Stewart on Nov 2, 2016 7:07 pm

We document all equipment used (Bair Huggers, Bovie, Fluid Warmer, Camera, Light Source, Laser, Smoke Evacuator, etc.) anything that has an ID number is charted. 

Re: Documentation of Equipment use

posted by Kendra Hardy Dunnigan on Nov 3, 2016 8:52 am

We also document all equipment used.

Spin off of this quesiton: is any one using arefernece book to keep numbers in and just calling the machine ESU #1, #2 etc? Currently we document the entire number, but some of the staff would like to do this- wanted to see if any one has had success with this method.
 

Re: Documentation of Equipment use

posted by Dawn Hampton on Nov 3, 2016 1:48 pm

We document the Biomed number of the units in the intra-operative record.  We use Epic; equipment such as ESU, SCD machine, tourniquet, Bair Hugger, etc., is pre-loaded and there is a drop down box that allows the nurse to click on the correct unit number and it automaticlly populates the record.  The staff in the OR write down the numbers of the equipment in the room at the beginning of the day and put it on a sticky note or label, it's on their computer so they can refer to it all day.

Re: Documentation of Equipment use

posted by Christine English on Nov 4, 2016 9:52 am

Do you retire the easy number (like #1, #34) if that piece of equipment is removed from service?

Re: Documentation of Equipment use

posted by Kristin Davis on Feb 12, 2018 4:26 pm

Staff are good about documenting some numbers for equipment, but not all.  Does anyone have a resource that specifies what is mandatory to chart (if any)?  If it is mandatory, it may help with complinace in this.

Thank you,
Kristin

Re: Documentation of Equipment use

posted by Jennifer Hehl on Feb 13, 2018 11:54 am

We also document equipment with full 5 or 6 digit biomed number from the stickers our biomed place on items.  We chart the top 5 most commonly used that have direct action or contact with patient (bovie, tourniquet, carm, scd, and bair hugger) but do not chart items that are not so direct on patient {neptune suction machine, microscope used, biomed number of exact OR table used (but we do note the type of bed - ie: jackson flat , trios fracture top, Glide top bed, etc...), also we do not note the scope equipment}.   

A related question for all of you: Are you charting biomed numbers of robotic equipment? We are currently debating if we need to chart the exact Mako or Mazor robot used on each case or not, and are not sure if we need to capture the robot used, or the sterile power tool attached to it or both to give us meaningful information.  

Re: Documentation of Equipment use

posted by Juliana Mower on Feb 14, 2018 10:46 am

Hello-this is an interesting discussion. Obviously we cannot document every piece of equipment used on a patient-but I would think those items that have the greatest risk for harm (e.g., tourniquet, ESU unit) should have top billing, as that would make it easier to trace back to the affending item. In addition to risk mitigation, those items that are billed may also want to be documented on the patient record for audit purposes. I believe that transparency in costs will become more common as we look for ways to control our expenses.
Julie Mower, MSN, RN, CNS, CNS-CP, CNOR    

Re: Documentation of Equipment use

posted by Cynthia Thomas on Feb 15, 2018 9:41 am

We have all the equipment built into our MediTech system.  Staff is required to select all equipment for the case.  We have staff assigned in the evenings to monitor equipment that is in each OR.  A list of equipment tracking nuimbers for stationary equipment  (camera box, light sources, insufflators, bovie, etc) are kept next to the computer in each OR for accuracy.  If additional equipment is brought ito the room, the drop down box built into the computer system with all of our equipement, allows staff to select with ease.   If equipment has to go out for repair, the superuser staff assigned to this task makes sure it is adjusted on list.  This system as worked well for our hospital.  Hope this helps.

Re: Documentation of Equipment use

posted by Mary Von Ohlen on Feb 15, 2018 10:08 am

Yes, we document the number of the bovie machine and the grounding pad used. We have experienced a problem with one device and it caused an injury to the patient. We collected the bovie machine, cautery pencil and had the batch number for the grounding pad. Everything was tested and it turned out there was a problem with the machine surging. Since that point we always document the machine ID number and the grounding pad number on all cautery machines used.
Mary H. von Ohlen BSN, RN, LMT, CNOR

Re: Documentation of Equipment use

posted by Madelyn Smith on Mar 5, 2018 2:59 pm

I am working as Interim Director of surgical services at a hospital in Chicago.  I have noticed that the staff don't document the insufflator use ( settings, the up and downtimes, etc) on Robotic cases nor any laparoscopic cases.  They also don't document deep trendelenburg positioning on certain Robotic cases.   Some of the staff have worked at other facilities in the area and say that they have never documented this information.    In my experience all over the US it has been the practice to document any equipment that could cause harm to a patient in the legal record.  The interesting thing that they do is track the insufflator time on a piece of paper for tracking quality measures and think it is not important to put it in the legal record.  It appears from all of the comments I have seen here that is is important to document it.

Re: Documentation of Equipment use

posted by Carol Hogue on Mar 8, 2018 10:28 am

I’ve worked in the OR since before we had insufflators,  at many hospitals, primarily on the west coast, and have never seen insufflation times  documented, nor any indication as to which ones were being used (ie, portable towers).
Carol  Hogue

Re: Documentation of Equipment use

posted by Carol Hogue on Mar 8, 2018 10:52 am

Update on myself!! Let me rephrase that... I’ve been in the OR since 1978, which is before lap chole’s and appies , but not pre-GYN scopes. Still, never seen documentation of insufflation times.
If the rationale is “an item that can cause harm”, do you document anesthesia machine, ie they can get switched out for maintenance, etc. or scope pump ID? Not saying these shouldn’t be, but I’ve never seen it. Usually only see tourniquet and ESU machine ID’s charted.
Carol Hogue  

Re: Documentation of Equipment use

posted by Sara Kinkead on Mar 9, 2018 11:25 pm

We have each Ligasure, TQ box, and bairhugger marked with a number or letter and document that from a “drop down menu” in our EPIC charting. We also document the bovie pad lot number and Neptune safety verification (example don’t hook it up to a chest tube or closed drain) on each case. We do not document insufflation time or biomed/ identification number for camera, light source, insufflator, Neptune, scd box, or irrigation pump. We do document DaVinci and Mako robots and Navagation device in the same fashion as our Ligasure. 

Re: Documentation of Equipment use

posted by Shannon Taddeucci on Mar 11, 2018 4:35 am

We document serial numbers for ESU, ground pad. We also document bairhugger, blanketrol, level 1, and tourniquet serials as these are items that can cause serous patient harm if they malfunction. I’m not aware of any global list of mandatory items to document. In my experience it is subject to facility preference. 

Re: Documentation of Equipment use

posted by Melinda Noble on Mar 12, 2018 1:07 pm

The rule of thumb I have always given is to document every piece of equipment that is in use with the patient--in other words everything that could potentially hurt the patient if it went bonkers.  A monitor used in the procedure wouldn't be recorded, but an SCD machine that might squeeze the patient leg off WOULD be documented.  We have 21 ORs, with a lot of rotating supplies (and things we borrow from sister hospitals), so we use a 4 digit number assigned by our biomed department.  If we went to a shorthand method (#1, #2, etc.), we would have to have someone validate that periodically to show that the number corresponded to the correct piece of equipment.  If something DID happen to the patient, you would then be asked to show how you can prove that your #2 bed is really U4235... legally tricky.

Re: Documentation of Equipment use

posted by Eileen Giordano on Mar 12, 2018 1:56 pm

My fear is we are so busy typing and entering every lot # & equipment# we are spending more time with data entry than being with and assessing our patients! Hopefully someday we can just scan everything,including all disposables and ALL implants! More time with our patients!

Re: Documentation of Equipment use

posted by Melissa Backscheider on Mar 12, 2018 6:53 pm

We doccumment all equipment. That being said- we have assigned a number to each bovie, bipolar, etc and the serial number is loaded in the computer, son that we can choose bovie # 3  and the serial number is prepopulaterd for us. We can then add pad site and settings.

Re: Documentation of Equipment use

posted by Anne Landgraf on Mar 13, 2018 4:14 pm

We use the serial number. That way there is no question which machine was used. Each facility within our health organization sent Epic their equipment and serial numbers and when charting only your facilities equipment numbers show up in the drop down screen. At our particular hospital there is a label (made with label maker therefore wipeable) with the last four numbers of serial number on all sides of the piece of equipment. When charting no matter how the machine is facing you can read the numbers usually from across the room.

Re: Documentation of Equipment use

posted by Michele Dunne on Mar 14, 2018 10:31 am

We have been frustrated by the explosion of documentation requirements, as well. We have, however, been able to institute barcode scanning of all our implants. I am the service leader for orthopedics and I don't have to tell you, documenting implants can be a nightmare! I worked along with our revenue coordinator and IT to implement barcode scanning of implants. It's been so incredibly wonderful, and such a time saver. I can't thank them enough for making one part of my job easier. Some of our supplies can be scanned into the computer also. That wasn't the initial goal, but it's a nice benefit!

As for documenting equipment, we document the Serial number of all equipment used on patients. Just make sense, and yes, especially from a legal standpoint. We used to assign a # (1,2,3, etc), but with so many pieces of equipment, it became difficult to keep track. 

 

Re: Documentation of Equipment use

posted by Michele Profeta on Mar 19, 2018 10:47 am

We docuument the Tag # of our Cautery unit as well as the serial # of the grounding pad used.  This is the only way to be able to track equipement involved in the event of a malfunction of a machine and/or ground pad.

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