Clinical Staff Documentation
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
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
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
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
2. Peri-operative documentation:
A. Names of personnel directly involved with performance
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
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
I. Manner in which and with whom patient left facility.
4. The use of verbal orders is minimized in this
A. Verbal orders may only be given to another clinical
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
6. All entries on the patient's chart will be legible and
Approved By Governing Board