{"id":866,"date":"2022-12-01T07:00:47","date_gmt":"2022-12-01T07:00:47","guid":{"rendered":"https:\/\/perioperative1000.slc-courses.ca\/?p=866"},"modified":"2022-12-15T12:13:32","modified_gmt":"2022-12-15T12:13:32","slug":"module-8-d-documentation-through-the-perioperative-phases-of-care-postoperative-handover","status":"publish","type":"post","link":"https:\/\/perioperative1000.slc-courses.ca\/?p=866","title":{"rendered":"Module 8: D. Documentation through the perioperative phases of care: Postoperative Handover"},"content":{"rendered":"\n

Documentation through the Perioperative Phases of Care: Postoperative Handover<\/h2>\n\n\n\n
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After the surgery is complete, the perioperative nurse helps to transfer the patient to the post-operative recovery unit (PACU). The nurse is responsible for providing a handover report which will be discussed further in course two. The circulating nurse must ensure that during handover, the following documentation is highlighted: <\/p>\n\n\n\n

  1. Patient <\/a>status (airway, breathing, circulation, hemodynamics, temperature). <\/li>
  2. Patient identifiers, weight, age. <\/li>
  3. Any allergies. <\/li>
  4. Type of anesthesia provided. <\/li>
  5. Pertinent diagnosis and medical history, as well as the surgery performed. <\/li>
  6. Any intraoperative events or complications that may have occurred. <\/li>
  7. Skin condition, including any areas of concern or breakdown during the intraoperative period. <\/li>
  8. Intraoperative medications given. <\/li>
  9. IV fluids and lines present. <\/li>
  10. Drains and catheters present. <\/li>
  11. Surgical site information, including any packing, dressing type, and drains. <\/li>
  12. Post operative plan. <\/li><\/ol>\n\n\n\n

    (AORN, 2021; ORNAC, 2021 \u2013 3.10) <\/p>\n<\/div>\n\n\n\n

    \n
    \"\"<\/figure>\n<\/div>\n<\/div>\n\n\n\n

    <\/p>\n\n\n\n

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    \"\"<\/figure>\n<\/div>\n\n\n\n
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    Electronic Documentation<\/h5>\n\n\n\n

    Most facilities use electronic documentation to support the fast-paced workflow. Depending on the facility, these records may be integrated into the electronic charting system or <\/a>may be printed and added to the patient\u2019s physical chart once <\/a>the procedure is completed. Perioperative nurses receive training at their home facility in using the electronic charting record. <\/p>\n\n\n\n

    \n It is important that all perioperative nurses are trained in \u2018downtime\u2019 procedures. There is always a chance that the computer system may require repair or updating. Having a paper backup charting system is essential to ensure that all data and information related to the surgery is captured. Each hospital facility must have a procedure for downtime paper charting and recovery of data once the computer system is functional.\n<\/p>\n\n\n\n

    Hospitals are required to have policies related to the access of patient charts. Perioperative personnel must follow these policies to ensure patient privacy and the security of electronic records. <\/p>\n\n\n\n

    (ORNAC, 2021 \u2013 3.10) <\/p>\n<\/div>\n<\/div>\n\n\n\n

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    Making Changes to Documentation<\/h5>\n\n\n\n

    Although most charting is performed using computer systems in the perioperative environment, there is documentation that remains paper-based, such as count sheets. Perioperative nurses must follow the health care organization\u2019s specific policy for correcting paper and computer entries. This could include: <\/p>\n\n\n\n

    1. Drawing a single line through an incorrect entry. <\/li>
    2. Dating and timing the change. <\/li>
    3. <\/a> Initial <\/a>correction. <\/li>
    4. Entering the correct information. <\/li><\/ol>\n\n\n\n

      (ORNAC, 2021 \u2013 3.10) <\/p>\n<\/div>\n\n\n\n

      \n

      <\/p>\n","protected":false},"excerpt":{"rendered":"

      Documentation through the Perioperative Phases of Care: Postoperative Handover After the surgery is complete, the perioperative nurse helps to transfer the patient to the post-operative recovery unit (PACU). The nurse is responsible for providing a handover report which will be discussed further in course two. The circulating nurse must ensure that during handover, the following […]<\/p>\n","protected":false},"author":5,"featured_media":70,"comment_status":"open","ping_status":"open","sticky":false,"template":"templates\/template-content.php","format":"standard","meta":[],"categories":[20],"tags":[],"wf_post_folders":[9],"_links":{"self":[{"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/posts\/866"}],"collection":[{"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/users\/5"}],"replies":[{"embeddable":true,"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=866"}],"version-history":[{"count":13,"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/posts\/866\/revisions"}],"predecessor-version":[{"id":1337,"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/posts\/866\/revisions\/1337"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/media\/70"}],"wp:attachment":[{"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=866"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=866"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=866"},{"taxonomy":"wf_post_folders","embeddable":true,"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fwf_post_folders&post=866"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}