Documentation Documentation…

29 Apr Documentation Documentation…

So tell me what are your thoughts on the amount of documentation we are asked to complete whilst we are caring for our patient under anaesthetic.

In the hospitals I have worked, we have a scrub nurse, anaesthetic nurse & circulator or scout nurse. The documentation is both paper and electronic. Responsibilities about paper work vary, as a rule this is how it generally plays out, here in Australia.

1) Pre admission checklist usually completed by the anaesthetic nurse

2) Scanning of instrument trays or attaching stickers to patient notes

3) Time Out Checklist/ VTE Assessment- scrub/scout team

4) Intra – Operative nursing care form- scout nurse

5) Count Sheet- scrub/scout team

6) Chargeable Sheet- scout nurse

7) Prosthesis Sheet-scout nurse

Not to forget

8) Pathology documentation

I am sure that I may have missed some, please contact me regarding any other types of documentation your health facility may have.

I know there are a number of hospitals who still do not have computers in their operating rooms, as a result this documentation is completed manually. Then there are some OR’s that do have computers but not all of the documentation can be accessed via a PC, this requires us multi tasking on paper and PC.

What are your thoughts on this, is there an easier and more efficient way of managing this mandatory paper work. I think we are all in the same vote, although I am not sure if this process works any better in other parts of the world. Would appreciate your thoughts on this.

Regards

Marrianne (Allis Technology)