Clinical Staff Documentation


 
POLICY:  
 
A complete and accurate patient record is prepared for every 
patient.  Responsibilities of clinical staff regarding 
documentation at each step of the surgical procedure are 
documented below.
 
The organization's process for effective handoff 
communication includes up to date information regarding the 
patient's care, treatment and services, condition, and any 
recent or anticipated changes. There is an opportunity for 
the receiver of the handoff information to receive relevant 
patient historical data, which may include previous care, 
treatment, and services.  Interruptions during hand offs are 
limited to minimize the possibility that information would 
fail to be conveyed or would be forgotten.
 
A process exists for verification of the received 
information, including repeat back or read back as 
appropriate.
In this organization hand off occurs between :

- pre operative medical assistant and surgeon

- pre operative medical assistant and anesthesiologist

- pre operative medical assistant and procedure assistant

- procedure assistant and circulating assistant

- circulating assistant and surgeon/anesthesiologis

- physician to patient and or escort


 
 
PROCEDURE:
 
1.  Pre-operative documentation:
    A.  Assure completeness of chart.
    B.  Document procedure proposed and pre-op diagnosis
    c.  Document designated driver  
    D.  Note vital signs, treatments, and patient assessment.
    E.  Document patient medical and surgical history,    
        medications, and allergies
    F.  Document NPO
    G.  Document all peri-operative teaching
    H.  Document patient vital signs
    I.  Document any barriers to learning needs, or 
        functional ability
 
2.  Peri-operative documentation:
 
    A.  Names of personnel directly involved with performance
        of procedure.
    B.  Diagnosis.
    C.  Surgical procedure to be performed.
    D.  Verify correct patient and procedure with physician, 
        anesthesia provider, and other clinical staff.
    E.  Documentation of IV
    F.   Documentation of patient's pain level
    G. Documentation of patient's vital signs during procedure
    H.  Use of cautery(settings, placement of grounding pad,
        integrity of  skin; after removal of pad) or 
        tourniquet.
    I.  Any complication or unusual occurrences.
    J.  If requested by surgeon, time of transfer of
        patient from OR.
 
 
3.  Post-operative documentation:
 
    A.  Patient's condition upon completion of procedure
    B.  Vital signs on regular basis while in recovery room.

    C. Oxygen use
    D.  Patient's comfort and self-reported pain level.
    E.  Medications administered.
    F.  Complications or unusual occurrences.
    G.  Discharge status: patient condition, time.
    H.  Review of discharge instructions with patient and
        caregiver.
    I.  Manner in which and with whom patient left facility.
 
4.  The use of verbal orders is minimized in this 
    organization.
   
    A.  Verbal orders may only be given to another clinical
        staff member.  
    B.  The staff person taking the verbal order must record
        the order into the patient's medical record and read the order back for verification.
    C.  The medical record containing the verbal order is
        returned to the appropriate surgeon to be co-signed
        within 24 hours.  
 
5.  Following a procedure, a member
    of our staff will call the patient, consistent with our
    call back policy. The information received will be 
    entered into the patient's medical record. 
 
    Significant medical advice given to a patient by 
    telephone is entered in the patient's record and signed 
    or initialed.  If a log is used to record the results
    of post-procedure calls, such advice or information
    regarding important patient questions or clinical 
    information will be transferred to the patient
    medical record.
 
6.  All entries on the patient's chart will be legible and 
    signed.
 
Approved By Governing Board    
PE.7    
Control #65.9
GUPTA GASTRO