E Muriel Gagnon, RN

A missing link: OR nurses’ notes Nursing care has always been practiced in the operating room. However, it has not always been documented and become part of the patient’s record. A t Quincy City Hospital, Quincy, Mass, we use a retrospective audit to evaluate the total care of the patient in the hospital and the expected outcome derived from that care. In reviewing the audit, we noted that nursing care of the surgical patient in the operating room could not be evaluated because there was no documentation. To correct this void, we established a protocol for “Operating room nurses’ notes.” The proposal for the notes was enthusiastically accepted by the director of nurses. But, it was viewed with skepticism by recovery room and floor nurses because they questioned whether the proposal would become a reality. Before designing the notes, we asked operating room nurses what information they considered pertinent to include, exclusive of what was charted on the anesthesia sheet. Recovery room and floor nurses were questioned to determine the information they wanted about patients returning from the operating room. After all suggestions were considered, a combination ~

E Muriel Gagnon, R N , is assistant operating room supervisor at Quincy City Hospital, Quincy, Mass. She is a graduate of the Boston City Hospital School of Nursing.

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checklist and write-in sheet was drafted (Fig 1).This compact style was chosen because so many operating room forms, such as operative notes and instrument, needle, and sponge counts, must be completed, there is not enough time for lengthy writing. The OR nurses’ note sheet and other forms are stamped and placed in the chart when the patient is admitted to the operating room. The circulating nurse fills out the OR nurses’ notes as time permits during surgery and must complete it by the time the patient leaves the operating room. The initial skepticism of the recovery room and floor nurses has changed to appreciation. They now know, for example, the exact location and type of drain in the patient. They feel that with the information given, they can better care for and understand the needs of the postoperative patient. The notes also have resulted in better communication between operating room and floor nurses. If there are any questions about the patient, the OR nurse who circulated on the procedure can be contacted directly. Our nursing care plan outlines the information that should accompany the patient to the operating room. Interview sheets give details with respect to past medical history, social history, and physical and emotional needs. The preoperative checklist informs the circulating nurse as to the preparedness of the patient for surgery such as laboratory work, x-rays, vital signs, and allergies. The surgeon’s preoperative notes, history and physi-

AORN Journal, October 1976, Vol24, No 4

Quincy City Hospital OR Nurses’ Notes Operation: ~

PostoD Diaanosis: Anesthesia: general Level of responsiveness:

I

Iawake

I spinal

I local

Iother

Idrowsy

1 asleep

Disabilities: Skin condition: I preop lndwellina catheter: I to OR

I PostoP I in OR

I to OR

Urinary drainage:

I

I

I in OR

Levin tube: to OR in OR Position: dorsal recumbent lithotomy I lateral I Sims I Fowler’s Scrub solution I Prep solution Position of ground plate: Tourniquet: no yes location Prosthesis, implants, grafts, foreign bodies:

I

I

I

I

inserted: removed: Wound drains: type Specimen: lyes ]no Wound irrigations: Medication by nurse: X-ray taken in OR:

I

prone

I other

I time

I

I

Cultures:

I yes I no

I location

I

FS:

I yes I no

1 Type tape:

Dressing: stretcher

to OR

I

Disposition: RR Complications:

I ICU

bed

I ward

I OP

crib

I other

Remarks: Sponge count:

I Circulating nurse:

Fig 1. Information included in this chart facilitates evaluating nursing care in the operating room at Quincy City Hospital, Quincy, Mass.

cal examination are included in the chart. Postoperative care has also been documented. The missing link in the total recorded nursing care of the surgical patient has been eliminated with the implementation of the OR nurses’ notes.

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We feel the chart will improve communication with other departments and aid us in reaching our goal of total quality nursing care. It will also provide a better tool with which to evaluate and improve nursing care in the operating room. 0

AORN Journal. October 1976, V o l 2 4 , No 4