Sample Patient Medical Records by wfc24018

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Sample Patient Medical Records document sample

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									                     AORN Sample Patient Records



T
       he AORN sample patient records on the              ments. In addition, any clinical record should pro-
       following pages are representations of many        vide an opportunity for clinicians to document the
       of the data fields used in the majority of         unique needs of the patient as well as age-specific
hospital settings. Their purpose is to demonstrate        and cultural needs and interventions. For a paper
a consistent approach to documenting nursing              record, additional (addendum) forms might be
assessment; identification of clinical problems;          required. For example, an orthopedic specialty
and nursing interventions, activities, and out-           hospital might have an addendum form for the
comes in a paper format. It is expected that clini-       numerous implants it might use for a single case or
cians will use these samples as a beginning point         an addendum form for blood administration.
to develop population-specific and facility-perti-
nent clinical records.                                        Some data fields in the same records have the
                                                          PNDS unique identifier in parentheses to illus-
     Such clinical records should incorporate data        trate how the PNDS terminology can be used in
fields that best represent the case types, clinical       patient records. These identifiers do not need to
situations, and patient experiences within a partic-      appear on a facility’s paper or electronic record.
ular setting. Such records could build upon these
samples, but also should reflect departmental/facil-      Feedback about these clinical records can be forward-
ity policies and procedures, AORN recommended             ed to the Center for Nursing Practice at (800) 755-
practices, and any pertinent regulatory require-          2676, ext. 264 or pndsrecord@aorn.org.


These records and related data fields incorporate the following references:

For time definitions:
Association of Anesthesia Clinical Directors, “Glossary of Times Used for Scheduling and Monitoring of
Diagnostic and Therapeutic Procedures,” http://www.aacdhq.org/glossary.htm.

For the Autar DVT Scale:
R Autar, “Nursing assessment of clients at risk of deep vein thrombosis (DVT): The Autar DVT scale,”
Journal of Advanced Nursing 23 (April 1996) 763-770.

For the PNDS:
S C Beyea, ed, Perioperative Nursing Data Set (Denver: AORN, Inc, 2002).

For documentation standards:
Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2002).




                                  Perioperative Nursing Data Set, 2nd edition                                 1
                    AORN SAMPLE Patient Record                                                               Addressograph
                     (Facility Name and Address)
NOTE: This record is a sample only. Clinical records should be customized to
incorporate data fields that represent the setting, facility, procedure, and patient.                    (Patient Information:
Reproductions and variations are encouraged, provided credit is given to AORN.              name, age, gender, medical record number, date)

Date:________________
Structural Data:
                     Operating Room Progress Notes                                      Surgeon 1:                     Circulating nurse 1:

Suite #:           ASA:                  Pt. in room:          Anes. start:
                                                                                        Surgeon 2:                     Circulating nurse 2:

Procedure start: Procedure finish: Pt. out of room:            Anes. finish:
                                                                                        Assistant 1:                   Circ. 1 relief:
                                                                                                                       Time in:________ Time out:______

Anesthesia type:                                                                        Assistant 2:                   Circ. 2 relief:
     General             MAC                    Spinal                Epidural                                         Time in:________ Time out:______

                                                                                        Anesthesia care provider 1:    Scrub 1:
     Local block, Type:__________               Other:_________________

Pre-Op Dx:                                                                              Anesthesia care provider 2:    Scrub 2:


                                                                                        Laser operator:                Scrub 1 relief:
Procedure(s):
                                                                                                                       Time in:________ Time out:______
                                                                                        Other authorized personnel:   Scrub 2 relief:
Post-Op Dx:
                                                                                                                      Time in:________ Time out:______

Nursing Data Elements—Preoperative:

    Preoperative checklist reviewed/evaluated

Risk for injury related to transfer and transport (X29):                                       Risk for anxiety related to knowledge deficit
   Pt. ID confirmed           Consent verified          Site verified                          and stress of surgery (X4):
   Allergies verified                                   Procedure verified                     Psychosocial status:
   Latex allergy:       Yes         No                  NPO verified                                 Calm/relaxed        Anxious       Talkative
                                                         Time:__________                             Crying               Restless
                                                                                                     Other:_______________________________
LOC:           Alert/oriented   Drowsy           Sedated                                          Provided instruction based on age and
               Asleep           Unresponsive     Disoriented                                      identified needs (I106).
               Other:_____________________________________________                                Communicated patient concerns to
                                                                                                  appropriate members of health care team (I128).
Skin:          Cool             Warm              Intact                                          Explained sequence of events and
               Dry              Moist             Body jewelry removed                            perioperative routine (I56).
               Tattoos:____________________________________________                               Evaluated response to instructions (I50).

Sensory impairment:                  No limitations           Hearing                          Risk for acute/chronic pain (X38, X74):
                                     Language barrier         Sight                               Instructed on use of pain scale
                                                                                                  Pain assessment (0-10):__________________
Musculoskeletal status:              No limitations         Paralysis          Traction           Location:______________________________
                                                                                               Outcomes:
Prosthetics/Assistive devices:           Hearing aid          Glasses
                                                                                                 Verbalizes/indicates decreased anxiety,
                                         AICD                                                    ability to cope, understanding of procedure
                                         Prosthetics:______________________                      and sequence of events. Questions answered.
                                                                                                 Demonstrates adequate pain management.
Cardiopulmonary status:
                                                                                                 Verbalizes comfort related to transfer/transport.
  Peripheral edema:               Yes Location:_________________________
                                  No                                                           Transfer to suite via:
   DVT/PE risk:           High               Med.             Low                                 Stretcher           W/C                  Bed
   Respiratory:           Tracheotomy        Intubated        Chest tube                          Isolette            Crib
                          Regular            Labored          Other findings
                                         _______________________________

        2                                           Perioperative Nursing Data Set, 2nd edition
Intraoperative Structural Data:
    EKG          Oximeter      NIAPB        Temp monitor         OR medications: (other than those given by anesthesia care provider)
 Implants/Prosthesis:      Yes      No   Exp. Date:______        Time    Medication             Dosage           Route        Initials
 Manufacturer:_______________________________________            _____________________________________________________
 Type: _____________________________________________             _____________________________________________________
                                                                 _____________________________________________________
 Size:______________________________________________
                                                                 _____________________________________________________
 Lot/Serial #: ________________________________________
                                                                 _____________________________________________________
Blood products:       Yes            No                     X-rays:       Yes             No    Pathology specimens:
                  Blood band #:_____________                                                    Routine:              Yes          No
                                                            Site: ______________________
Unit #:______ Start time:_______ Finish time:______         Type: _____________________                                 #:__________
Unit #:______ Start time:_______ Finish time:______                                             Frozen section:       Yes          No
                                                            Protective devices:
                                                               Gonadal          Thyroid                                 #:__________
Unit #:______ Start time:_______ Finish time:______
                                                            Other: ____________________         Cultures:             Yes          No
Blood recovery:      Yes      No Unit #:__________                                                                      #:__________
                   CCs reinfused:__________________        Grafts:        Yes             No
                                                                                                Comments:_____________________
                                                           Type: _____________________          ______________________________
Irrigation:
Type: _______________________________________              Donor site: _________________        ______________________________
 Amount: _____________________________________             Recipient site: ______________     ______________________________
Intraoperative Nursing Data:
 Risk for infection (X28):                    Risk for impaired skin integrity (X50):
    Skin Pre-op intact      Other: _________ Position for surgery:       Supine         Prone           Mod. lithotomy      Jackknife
    Surgical clippers: ____________________                              Lt. lateral    Rt. lateral     Other:_________________
    Area: ______________________________ Positioning devices:              Chest roll           Shoulder roll          Axillary roll
    Skin prep      By: ____________________                                Pillow/wedge         Stirrups               Leg holder
       Povidone iodine          Chlorhexidine Pad bony prominences:        Elbows         Heels           Arms tucked/padded
       Other: __________________________                                   Other:_______________________________________
                                              Positioned by: _______________________________________________________
 Wound classification:
    1-Clean                    3-Contaminated Risk for injury (X29):
    2-Clean/contaminated       4-Dirty           Apply safety strap to: _______________________________________________
                                                   Apply grounding pad          Site: _______________________
   Urinary catheter:                               Electrosurgical unit #: __________      Bipolar #:__________
   (size/type/site): ______________________        Setting: Coag:_______ Cut:________
   OR output:____ Inserted by:___________
                                              Laser Type:________ Unit #:______ Settings:_________ Time:_________
   Drains/tubes (size/type/site): ___________    Safety measures implemented      Operator:__________________________
   OR drainage amount:_________________
                                              Tourniquet checked & applied #:_____ Site: _______ Applied by:___________
   Packing (size/type/site): _______________
                                                 Inflated: ______    Deflated:_______    Pressure:____________________
   Cast (type/site): _____________________
   Dressing (type/site): __________________ Sequential stockings:  Yes       No         Other:_________ Unit #:_______

Risk for hypothermia (X26):                Counts:                  Sponge          Needles           Instruments
   Apply warming blanket #: ______________         1st count:          Correct         Correct           Correct
   Temp setting:________                           2nd count:          Correct         Correct           Correct
   Applied by: _________________________           3rd count:          Correct         Correct           Correct
                                                                       Unresolved      Unresolved        Unresolved
   Warm IV fluid
                                                                       N/A             N/A               N/A
   Warm irrigation                           Surgeon notified of counts If counts unresolved, X-ray taken:    Yes   No
   Other: _____________________________ Signature:________________ If no, explain: _____________________________
Postprocedure Assessment/Evaluation:
Outcomes:            Patient’s surgery performed using aseptic technique and in a manner to prevent cross-contamination (O10).
                     Skin remains smooth, intact, non-reddened, non-irritated, free of bruising (O5, O2, O8).
                     Core body temperature remains in expected range (O12).
Patient discharged to:       PACU         Room           ICU        Time:             Report given to:
via:      Stretcher      W/C      Bed      Isolette       Crib
Pain scale: 0-10__________          Unable to assess
Condition:     Temp:_________           Skin:       Cool       Warm       Dry      Intact      Moist     Pink
    Intubated        Extubated        Awake           Alert           Expired:_________     Other:_____________________
    Family provided status report                                   RN Signature:
Comments:                                                           X
                                            Perioperative Nursing Data Set, 2nd edition                                      3

								
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