1. SURGICAL FORMS AND RECORDS

2. TERMINAL OBJECTIVE: Complete selected forms and records

3. ENABLING OBJECTIVES 1. Given simulated data, complete surgical forms and records 2. Prepare surgical forms and records for use during a surgical procedure

4. PURPOSE: Documentation Verbal communication between patients and health care providers does not constitute legal evidence in a court of law Records identify what occurred and what didn’t occur

5. Purpose Means of communication between providers during course of treatment

6. Standard Form 515 (Tissue Examination) Intraoperative record of any tissue or item removed from patient during procedure Can be used for more than one tissue specimen

7. Gallbladder Appendix Bullet

8. Standard Form 515 (Tissue Examination) Labeled in the order removed Specimens labeled using letters First specimen labeled “A”, etc… A

9. Standard Form 515 (Tissue Examination) Cultures labeled using numbers First culture labeled “1”, etc… 1

10. Standard Form 515 (Tissue Examination) Additional documentation is required on any specimen that is tagged identifying a specific margin or location Breast tumor

11. Standard Form 515 (Tissue Examination) Pertinent information required Surgeon’s name Name of specimen Clinical history Diagnoses:

12. Specimen Labels Addressographed self adhesive labels Used one per specimen obtained during surgical procedure Label made by patient runner or nurse on arrival of patient to holding area

13. Specimen Labels Clearly labeled with: Patient name Hospital register number Social Security number Type of specimen Operating room number Surgeon’s name

14. Standard Form 516 (Operation Report) Records the number of personnel involved inside that operating room Surgeon First/Second Assistant Anesthesia provider Nurses Technologists: Scrub, Circulator, Students

15. Student scrub Staff scrub Circulating nurse Surgeon 1 st assist 2 nd assist

16. Standard Form 516 (Operation Report) Pertinent information Times Start and stops of: Anesthesia Operation Diagnosis Preoperative Operative

17. Standard Form 516 (Operation Report) Sponge count Drains Operation Procedure performed Description

18. Standard Form 516 (Operation Report) Wound classification Implants Specimens Cultures Complications Tourniquet times

19. Sponge, Needle, and Small Count Sheet Hospital specific Intraoperative for counted items added to the sterile field Sponges Needles Small count items

20. Sponge, Needle, and Small Count Sheet Technologist adding items to sterile field should: Initial above item added Place his/her signature in space provided

21. Sponge, Needle, and Small Count Sheet Documentation of relief count is done on bottom of worksheet Completion of all appropriate counts by O.R. nurse is documented with word CORRECT or INCORRECT on SF 516

22. Laboratory Requests Hematology CBC Differential Platelets Microbiology Cultures/Smears Blood Gas Analysis-ph

23. Standard Form 518 Blood or Blood Component Transfusion-used to request blood and components Can only be requested by: Medical/Dental officers Anesthesia providers Verbal order may be taken by registered nurse

24. Newborn paperwork Used during C-sections: Operating room L&D Newborn I.D. Sheet Baby’s ID band Blood Bank/Cord Blood request Serology request

25. Standard Form 522 Request for Admission of Anesthesia and Performance of Operation/Other procedures Informed consent to administer anesthesia and perform operative procedure

26. Standard Form 522 Describes the procedure in laymen’s terms Signed: Patient Parent Legal guardian

27. Standard Form 522 Witnessed by someone that is not a member of the operating team. Surgical procedure performed without signed witnessed informed consent

28. Standard Form 522 Surgeon is ultimately responsible for obtaining consent Signed prior to pre-operative medications

29. Standard Form 519-A Radiological Consultation Request Used for X-Rays to be taken Fractures Cholangiograms Placement of catheters Lost countable items

30. Incident Report Used to document an injury to a patient or caregiver Complete and accurate record of events Part of departmental quality improvement and risk management program

31. REVIEW AND SUMMARY

32. SURGICAL FORMS AND RECORDS If you didn’t write it down? It didn’t happen! THE END