Search Discussions

Recent Topics

Relevance
Ana Chozet-Griggs
Documentation
1 45
Hello All, I am checking in with you to see if anyone has a competency specific to the eye surgical service? We are ...
Ana Chozet-Griggs Category Documentation 7d
Stephanie Mitchell Stephanie Mitchell 6d
I would like a look at this as well. Thank you, Stephanie Mitchell
Elizabeth Austin Evans
Liposomal Bupivacaine Intraoperative Time Out
5 67
Dear Colleagues, An OR RN asked about a formal time out prior to the administration of Liposomal Bupivacaine. The ...
Elizabeth Austin Evans Category Documentation 11d
Autumn Rodriguez Autumn Rodriguez 8d
I have never done a time out prior to the administration of Exparel or worked in a facility where this was the ...
Meagan Peck
Postoperative Vital Signs
1 30
Hi all, Wondering how often your facilities are performing postoperative vital signs on patient that go to the ...
Meagan Peck Category Documentation 12d
Laura Heffley Laura Heffley 8d

@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
Preoperative Orders for Surgery Timing
1 27
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
Jenni White Jenni White 12d

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

Beth McCarthy
Load Sticker on Implant Record
17
Is it standard for a load sticker from an implant tray to be included in the intraop record? Can anyone provide ...
Beth McCarthy Category Documentation 14d
Cecilia Martinez
Moderate Sedation and EMR
18
Hi, We switched to Surginet in March. But most of our moderate sedation documentation is still on paper. Could ...
Cecilia Martinez Category Documentation 22d
Ellen Carr
Preference cards as medication orders
4 88
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
When is the end of surgery time for a Total Shoulder- ...
5 93
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
Kimbalie Moore Kimbalie Moore Aug '22

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

Aleta Bouchard
Re-opening of Incisions: New documentation?
2 53
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
Noeline Sui Noeline Sui Jul '22
For re-opening of incision, dressing or wound vac information is charted on the same existing active LDA so that ...
Rachael Rolfe
Medication - Documenting lot / expiration
56
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
Case cancellation after anesthesia. Is a discharge ...
1 36
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
Monica Moliniare Monica Moliniare 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
PNDS
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
Janice Kelly Janice Kelly 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
How do you document an unintentionally retained item ...
4 97
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
Brenda Larkin Brenda Larkin 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
Documenting Breast sizers
4 40
Hello, we are trying to standardize our breast implant documentation. Have found that staff are not documenting ...
Brenda Chapman Category Documentation Jun '22
Kathryn Ross Kathryn Ross 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
hand hygiene audits
3 127
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
Kendra Hardy Dunnigan Kendra Hardy Dunnigan May '22
Hi,
The joint commission has the TST hand hygiene audit tool. However I do not think it is relevant to the surgical ...

Trending Tags