In this series we have talked about the vital importance of counting, the timing of the counts, what is counted, and what happens if the count is wrong. Phew, it’s been a busy three months.
The last part of the series is arguably the most important, outside of the actual, you know, count.
And this is documenting.
Yes, nurses are very into documenting. And we should be as it is the record of the surgical case/patient’s day in the hospital/a record of interventions done. Very important.
There is an old phrase that was pounded into us as students.
Let’s say it all together now-
If you didn’t chart it, you didn’t do it.
If you didn’t document it, it wasn’t done.
No one who is at the hospital and is not you know what happened and didn’t happen during the course of a shift.
And even your memory may be incorrect, especially as time passes and our brains get busy with other patients, and other tasks.
The entire idea comes from a place of keeping the patients safe. And keeping the nurse safe. The if you didn’t document it, you didn’t do it refrain is to remind nurses that the chart is a record of the care given to the patient. And is of utmost importance when delivering care.
In the OR, it mostly revolves around counts. Our electronic health record has a handy, dandy space to document who performed which counts, and if they were correct or not. There is also a place to document the time the count was completed.
As discussed previously in this series, there are the absolute minimum counts that must be completed.
These are the beginning of the case and the end of the case counts, also known as skin-to-skin.
Absolute bare minimum.
There are other counts that need to occur. Such as cavity closure, or the beginning closing count. This is case-dependent and what and when these are counted may change.
There is also the relief count. If the circulator or the scrub tech is going on break or leaving for the day, the counts should be reviewed and, yes, documented that a relief count has been done.
Again, if you didn’t document it, which is what this is in the EHR, you didn’t do it. And will save yourself a phone call from the room after you’ve left as they frantically look for something missing. Or having to testify in a retained surgical item court case. Because despite our best efforts, things do happen.
The best advice I can give is to get into a routine of charting the counts, a rhythm to your charting.
But remember, as always, patient care comes before charting.
Dispatches from the Evening Shift 