Documentation through the Perioperative Phases of Care: Preoperatively
A lot of documentation is prepared and organized even before a patient arrives in the preoperative department. Many patients require testing, lab work, and assessments to be completed and documented before they can even be scheduled for surgery. It is important to follow individual hospital policies and procedures when determining what documentation should be completed before bringing a patient into the operating room. Many facilities have a checklist for perioperative personnel to follow to ensure all documentation is complete and present.
When a patient arrives in the pre-operative area (often called same-day admission unit – SDAU), the nurse reviews all paperwork and completes their initial assessment. This will be discussed further in course two. The perioperative nurse then collects the information from the pre-operative nurse and reviews it for completeness.
The perioperative nurse will then collect the information from the pre-operative nurse and review it for completeness.
Documentation needed:
- Surgical Consent
- Blood transfusion consent, if deemed necessary.
- Advanced directives
- Pre-surgical work up documentation, including lab work, any pre-surgical assessments or testing, blood type and screen if there is a risk for blood loss.
- Pre-surgical assessment from the nurse. This is done on the day of surgery and includes vital signs, weight, and any necessary pre-operative assessment as per hospital policy.
The perioperative nurse receives a handover report, either written or verbally, from the pre-operative nurse. This must be reviewed and documented.
The perioperative nurse meets the patient in the pre-operative waiting area and reviews all necessary documentation. They then complete their own assessment and verification. This includes all necessary checks and any physical assessment needed. The perioperative nurse must then document that this verification process has been completed as per hospital policy.