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Ana Chozet-Griggs
Hello All, I am checking in with you to see if anyone has a competency specific to the eye surgical service? We are ...
I would like a look at this as well. Thank you, Stephanie Mitchell
Elizabeth Austin Evans
Dear Colleagues, An OR RN asked about a formal time out prior to the administration of Liposomal Bupivacaine. The ...
I have never done a time out prior to the administration of Exparel or worked in a facility where this was the ...
Meagan Peck
Hi all, Wondering how often your facilities are performing postoperative vital signs on patient that go to the ...
Meagan Peck Category Documentation 12d

@Meagan Peck we are an outpatient center but thought I would give you what we do on the chance it helps you at all…

PACU ...

John Savage
We implemented a new EMR with Computerized Physician Order Entry in May of 2021. We have an issue with timeliness of ...
John Savage Category Documentation 13d

@John Savage
We recently rolled out something similar and continue to struggle with the doctors using paper at ...

Beth McCarthy
Is it standard for a load sticker from an implant tray to be included in the intraop record? Can anyone provide ...
Cecilia Martinez
Hi, We switched to Surginet in March. But most of our moderate sedation documentation is still on paper. Could ...
Ellen Carr
Does your facility require physicians to sign off preference cards for medication orders? Can they be standing ...
Ellen Carr Category Documentation Aug '22
Julie Zorn Julie Zorn Aug '22

@Ellen Carr it probably depends on the state. Our facility does not consider the pref card an order. We have to have ...

Ena Roseman
A CRNA stated surgery is not completed until the patient is put back in supine position- in all the years of being an ...
Ena Roseman Category Documentation Aug '22

@Ena Roseman
I have worked in different facilities where the stop time was closure of incision and application of ...

Aleta Bouchard
Should a re-opened incision be documented as a new incision in the LDAs? I was part of a case last week that needed ...
Aleta Bouchard Category Documentation Jul '22
For re-opening of incision, dressing or wound vac information is charted on the same existing active LDA so that ...
Rachael Rolfe
One of our nurses was instructing an orientee that for any medication that “stays in the body for over 30 days” (such ...
Rachael Rolfe Category Documentation Jul '22
Lisa Ensey
I just entered surgery after many years in ICU. Had a case that was cancelled due to inability to intubate. PT sent ...
Lisa Ensey Category Documentation Jul '22

All patients must have an order for discharge and discharge instructions even if it’s just to monitor IV site for ...

Kate McGee
1 49
Hello, I recently heard that the PNDS was retired? Does anyone have any information on that? I've been looking and I ...
Kate McGee Category Documentation Jul '22

@Kate McGee The PNDS is not retired. We are on the 4th version of the PNDS. The most current version of the PNDS is ...

Kimberly Mitchell
Do you have a standard process to document something like a broken piece of a drill bit or trial that cannot be ...
Kimberly Mitchell Category Documentation Jun '22

Kim, we don't currently have a policy on this, but, the retained item should be documented in such a manner that it ...

Brenda Chapman
Hello, we are trying to standardize our breast implant documentation. Have found that staff are not documenting ...
Brenda Chapman Category Documentation Jun '22

I have never documented sizers, neither on the OR record nor on the implant record. Only use the implant record for ...

Rebekah Morrison
I am in need of a good hand hygiene audit. Is anyone willing to share theirs from an ambulatory surgery center?
Rebekah Morrison Category Documentation May '22
Hi,
The joint commission has the TST hand hygiene audit tool. However I do not think it is relevant to the surgical ...

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