Preoperative documentation

Documentation purpose

record interactions between patients and care team

proper medical records

surgery: to outline what is happening during procedure (charging patients, implants, and specimens)

Importance of records

continuation of care

communication between all members of health care team

Patient charts

allergies

diagnostic tests

history and physical must be on chart before transporting to the OR

signed consents

surgeon orders

surgical safety checklist

Surgeon orders

start IV

NPO

CT, MRI, x ray

Consent

PT orders for medications and procedures

Records

informed consent

physician H&P

labs

pre op medications and Dr’s orders

Patient consent

TJC defines patient as one who has given consent to
receive health care services from health care provider
Patient = made personal decision to accept care
• Consent = permission to have action take place
• Can only be given if patient has capability and
authority to sign (Example : minor – parent would
consent

Consent format

express consent- verbal or written statement granting permission

implied consent- no direct verbal or written, but occurs when circumstances indicate to the health care provider that the patient had given consent for treatment. This is often inferred from a patient's actions or the nature of a situation, such as in emergencies where immediate care is necessary.

Types of consent

general consent- obtained upon admission to the hospital, relied on routine duties carried out in the hospital and may vary from hospital to hospital. when patient is admitted general consent is signed for “general treatment” i.e diagnostic test, routine care, broad consent

special consent (informed consent)

Advanced directives

living will- allows pt to refuse treatment to prolong life

DNR- do not resuscitate

DPA- durable power of attorney, designates the person authorized to make decisions should that patient become incapacitated

allow the patient to participate in their own decisions related to what type of care will be provided

Informed consent

consent to a particular procedure which may cause injury to patient, or would be considered battery.

legal document signed before surgery outlining type of surgery in medical and layman’s terms, risks benefits and outcomes, alternatives to surgery, patient understanding, acceptance, and must be done without intimidation or coercion

required for each operation, any procedure w anesthesia, procedures involving entrance into body cavity, high risk treatment like chemo, to receive blood products experimental treatment, receiving implants, sterilization, specimen and limb disposal

What makes a patient considered “informed”

patient should be informed on risks and about the procedure, diagnosis, medical alternatives, consequences should they refuse treatment

it is the responsibility of the surgeon to inform the patient of this, if the patient asks questions regarding these, contact the surgeon to answer !

Purpose of informed consent

Protect the patient’s right to self-determination regarding
surgical intervention
Protect the patient form unratified and unwanted procedures
Protect the surgeon and hospital from claims of unauthorized
operation or other invasive procedure

Validity of consent

must have patient’s full name, surgeons name, diagnosis, procedure, potential risks, patient’s signature and witness, date and time of signature. pt must be legal age, mentally alert, and competent

Special cases regarding consent

a minor- legal guardian must sign

emancipated minor can sign themselves

illiterate- pt can sign w an “X”

mentally incompetent- legal guardian signs or court

consent may also be given to courts, temporary guardian, or hospital administrator

In life threatening emergencies, consent is desired but not essential. Consent may be taken by telephone from a legal
substitute, but requires witnessing by two nurses. Two
physicians, not involved in the patient care, may deem surgery
necessary and sign permit

Witnessing a consent attests to

Identification of patient or legal substitute
• Fact that the signing was voluntary and without
coercion.
• Mental status of signatory

Withdraw consent

A rational patient may withdraw consent at any time prior to
surgical intervention.

Surgical Record

A legal account of the procedure and provides valuable
information to the post-op team
Anesthesia keeps their own records which will be added to the
chart postoperatively

O.R. records should include:
• Patient interview verification
• Verification of time out
• Date
• O.R. number
• Names of all personnel in room
• Surgeon
• Assistant
• Scrub(s)
• Circulator(s)
• Anesthesia
• Others

Surgical Safety Checklist

Guide to avoid incidents during surgery
• Checklist posted at facility
correct patient identification
Time-out (another lecture)

Surgical documentation- If it’s not documented,
it was never done!

Diagnosis – pre-op and post-op
• Surgical Procedure
• Times
• Anesthesia information and ASA class
• Wound Classification
• Position and aids
• Prep
• Shave

and

Catheterization
• Electrosurgery
• Tournequit
• Blood, Medications, Irrigations
• Specimens, Cultures
• Dressings, Drains, Packing
• Counts
• Implants