The gown card reads “Take credit for what you do. All documentation is important.”

This can be thought of in at least two ways.

Yes, write down everything you do during a surgical case. This is important. The OR documentation is a shell, it is up to you to fill in the details.

ALL the details.

This is to protect you when there is a complication.

All the positioning aids are important to note. It is also important to note what position the patient is in during the surgery. If you have to fudge the lithotomy a bit because of their body limitations, write that. Be as detailed as you can.

I don’t care if you’ve done this case 2000 times, document everything you’ve done.

All the medications are important to note. How will the pharmacy and nurses and doctors who take care of the patient AFTER they leave the OR know the details of what medication was given? Be detailed, not only in the medication dispensed to the field, but the total of the medication delivered to the patient. Don’t forget to include the route. Remember the 5 rules of giving medication to a patient from nursing school? Yeah, right patient, right time, right dose, right medication, right route. I would add another right; the right indication for use. If this medication is being used in a way that is unusual, write it down. Give justification as to why. If there are antibiotics added to bone cement, explain that.

All the dressing details are important, even if they can’t be seen without deconstructing the dressing. An addition of an antibiotic or non-adherent film is important to note. Because the nurse or doctor who will be taking down the dressing has to make sure they have all the pieces. Because some of that turns transparent against a wound.

All the people in the room are important. Not only is it up to the circulator to control the traffic in the room and keep the crowd down to necessary people only, but times are important. People I often see not listed on the chart as being present are the correct product representatives or x-ray techs. The times all the people in the room are present may be useful in the future. Not only for productivity tracking.

All the details of the equipment used are important. This is so we can track the equipment used and also aids in tracking down instrumentation if there is an issue with a later patient where the same equipment is used. It is often necessary to note when the equipment is used on patients.

All the supplies are important. In so many ways. This is important on the back end for ordering and correct billing.

Be as detailed as you want to be while charting. But remember, your charting might save your ass in a deposition during a lawsuit in 5 years, 18 if it involves an infant, or until age of maturity if it involves a child.