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Nina Johnson
Our computerized documentation system automatically fills in the Surgeon “time in” as the documented “cut ...
I have never heard of the incision time as being surgeon’s time in. We track the pt. time in and surgeons’s time in ...
Kristina Streb
Is there any regulatory guidelines that I can cite that state that there should not be any abbreviations on ...

I totally agree with you, the place where I work , we had put it in the facility consent policy , No abbreviation ...

Leslie Cassel Kelley
Do you document the amount of arthroscopic fluid irrigation on the operative record? Document pump settings ?
Sue Anderson
If the needle count matches the needle packages but less on the paper count sheet is it a reconciliation that can ...
Sue Anderson Category Documentation Aug '21

I've worked in one place where they said, yes- if you can trace it back and figure out where it came from; such as, ...

Karen Geittmann
Our pain management physicians withdraw and waste what is left in the pump when they refill pain pumps. This is ...
Karen Geittmann Category Documentation Jul '21
Melissa Waibel
I had a surgeon ask if anesthesia and circulator amend their documents post date of service if CPT code is changed ...
Melissa Waibel Category Documentation Jul '21
I have not encountered this but I would contact your Quality person in your facility.

Best,
Theresa
Patricia Boettger
Does anyone have a syntegrity cerner charting perioperative charting segment that autopopulates from the ...
Patricia Boettger Category Documentation Jun '21
Ann Dennis Ann Dennis Jul '21

Yes, we use Epic and all of that information flows into his brief op note

Elizabeth Yates
I would like to know if you document tissue sealants/hemostatic agents such as SurgiFlo, Vistaseal, Duraseal, ...
Elizabeth Yates Category Documentation Jun '21
Joy Chau Joy Chau Jun '21
At my facility, all tissue sealants/hemostatic agents are documented as implants with lot # and expiration ...
Julie Cahn
Good Morning, The Clinical Nursing Practice Committee is about to get started on creation of a hybrid OR tool kit. ...
Julie Cahn Category Documentation Jun '21
Warren Perry
Hey folks, Looking for some example of paper intraop records. My facility, in rural Upstate NY, is still using ...
Warren Perry Category Documentation May '21
Patricia Schlagel
Our healthcare system is looking to involve the Circ RN to document/order blood specimens drawn by the Anesthesia ...
Patricia Schlagel Category Documentation May '21
Demi Broderson
Hi everyone! I am interested in receiving feedback regarding POCT testing. We have new leadership and have had ...
Demi Broderson Category Documentation May '21
Our POCT department requires initial, 6-month, and 12-month training and demonstration of competency and then ...
Jennifer Metrejean
Can anyone share with me your EMR documentation for use of the mini c-arm? Location, dose, patient protection?
Monica Skeat
We are considering adding a quick button to our intraoperative EHR to document different ESU blend settings. Does ...
Monica Skeat Category Documentation Mar '21
Thomas Ludwig
Do any hospitals use a specific count sheet for their CVOR? Ours is requesting their own sheet and I am not sure if ...
Thomas Ludwig Category Documentation Feb '21
Yes, it would be wise to have a separate CVOR count sheet. There are more countable items in this service as well as ...

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