My Patient, My Chart!

Prior to implementation, the Charge Registered Nurse (RN) reviewed all Pre-Operative charts on day of surgery, and ensured the necessary elements were present prior to the patient going to surgery. The Charge RN was responsible for reviewing all lab work, diagnostic testing, and confirmed the presence of documented clearances (Cardiac, Pulmonary, etc.) if indicated. The Charge RN would communicate any abnormalities to the Surgeon and Anesthesiologist. The Pre-Operative Admitting RN would perform patient care and enter data into the Electronic Medical Record.

Source: Journal of PeriAnesthesia Nursing - August 1, 2018 Category: Nursing Authors: Maria Gutierrez, Patty Mendoza, Amor Eluna, Shannon Biehn Tags: ASPAN National Conference Abstract Source Type: research