DA 5179-1 1987-2024 free printable template

INTRAOPERATIVE DOCUMENT MEDICAL RECORD For use of this form see AR 40-66 the proponent agency is the office of The Surgeon General. 1. PATIENT TRANSPORTED TO OPERATING ROOM VIA BY 3. DATE TIME PATIENT ARRIVED IN SUITE 2. PATIENT IDENTIFIED RECORD REVIEWED AND PROCEDURE VERIFIED BY 4. PATIENT IN ROOM TIME NUMBER 5. PREOPERATIVE EMOTIONAL STATUS CALM ANXIOUS EXCITED CRYING ANGRY WITHDRAWN OTHER Specify COMMENTS 6. NURSING PERSONNEL ASSIGNED SCRUB RELIEF CIRCULATOR 7. POSITION AND POSITIONAL...

How to fill out operating room record sample

How to fill out operating room record sample:

1. Start by filling out the patient's information such as their name, date of birth, and medical record number.
2. Next, document the date and time of the procedure. This will be crucial for accurate record-keeping.
3. Record the details of the surgical team involved, including the surgeon, anesthesiologist, and any assisting personnel.
4. Document the preoperative assessment, which may include the patient's vital signs, any allergies, and relevant medical history.
5. During the procedure, record important information such as the type of surgery performed, specific instruments used, and any pertinent surgical findings.
6. Note the patient's vital signs throughout the procedure, including blood pressure, heart rate, and oxygen saturation levels.
7. Document any medications administered during the surgery, including anesthesia and postoperative pain medications.
8. Record any complications or adverse events that occur during the procedure, along with the actions taken to address them.
9. Finally, include a summary of postoperative care instructions given to the patient, as well as any follow-up appointments or tests recommended.

Who needs operating room record sample:

1. Surgeons and surgical teams: Operating room record samples are essential for surgeons to accurately document the details of surgical procedures they perform. It helps in maintaining a comprehensive record of the surgery for future reference, possible legal purposes, or research.
2. Anesthesiologists: Anesthesiologists need the operating room record sample to record the type and amount of anesthesia administered, as well as to document any complications or adverse reactions that may have occurred during the procedure.
3. Hospital administration and quality control: Operating room record samples are crucial for hospital administration and quality control to ensure proper documentation, adherence to protocols, and patient safety. They can be used for audits, research, and monitoring the standards of care provided in the operating room.

People Also Ask about operating room record sample

What needs to be documented in an operative report?

The minimum required elements include; the name of the primary surgeon and assistants procedures performed and description of each procedure findings any estimated blood loss, any specimens removed, and the post operative diagnosis.

How do you write an operative report?

Writing an operative note Write clearly and concisely. Use red ink if possible. Document the date and time (24 hour clock) State the operation performed, including the side (right or left), specific location, type of anaesthesia (general or local), and whether it was an emergency or an elective procedure.

How do you write a surgery report?

Writing an operative note Write clearly and concisely. Use red ink if possible. Document the date and time (24 hour clock) State the operation performed, including the side (right or left), specific location, type of anaesthesia (general or local), and whether it was an emergency or an elective procedure.

What is contained in an operative report?

The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The information in the operative report includes preoperative and postoperative diagnosis and the condition of the patient after the surgery.

What is operating room record?

The operating room record (including the operative/ surgical technique) should be submitted for all surgical procedures done in the operating room, delivery room, labor room, emergency room, and OPD minor operating room of the accredited facility.

How do you prepare a patient for an operating room?

Preparing for Surgery Stop drinking and eating for a certain period of time before the time of surgery. Bathe or clean, and possibly shave the area to be operated on. Undergo various blood tests, X-rays, electrocardiograms, or other procedures necessary for surgery.

For pdfFiller’s FAQs

What is operating room record sample?

An operating room record sample is a document that outlines the details of a surgery performed in an operating room. It typically includes information about the patient, surgeon, anesthesia provider, and any other medical personnel involved in the procedure. It also includes information about the procedure itself, including the type of procedure, any potential complications, and any post-operative instructions for the patient.

Who is required to file operating room record sample?

The operating room nurse, surgeon, anesthesiologist, and other staff members involved in a procedure are all required to file operating room records. Each record should include the patient's name, the procedure performed, the type of anesthesia used, and any complications encountered.

How to fill out operating room record sample?

1. Start by filling in the patient's name, date of birth, and medical record number. 2. Enter the date and time the patient entered the operating room. 3. Enter the name of the physician performing the procedure. 4. Enter the names and credentials of the operating room staff. 5. Enter the name of the procedure being performed. 6. Enter the type of anesthesia used and the name of the anesthesiologist. 7. Enter the type of instruments used and any special supplies needed. 8. Enter any other pertinent information that might be relevant. 9. Enter the date and time the patient left the operating room. 10. Sign and date the form.

What information must be reported on operating room record sample?

1. Patient's name, date of birth, and medical record number 2. Surgeon's name and specialty 3. Type of surgical procedure 4. Date and time procedure started and ended 5. Anesthesia type, dosage, and duration 6. Pre-operative diagnosis and operative findings 7. Description of the operative technique used 8. Post-operative diagnosis 9. Description of materials used and any implants placed 10. List of medications administered 11. List of any complications that occurred 12. Name of circulating nurse 13. Name of anesthesia provider 14. Name of scrub nurse 15. Name of recovery nurse 16. Name of any assistants present

What is the penalty for the late filing of operating room record sample?

The penalty for the late filing of operating room records will depend on the specific laws and regulations of the jurisdiction where the record is being filed. Generally, late filing of operating room records may result in fines, loss of professional license, or other penalties.

What is the purpose of operating room record sample?

The purpose of an operating room record sample is to document and record all the important information related to a surgical procedure that takes place in an operating room. This record serves as a comprehensive and detailed account of the surgical procedure, including patient information, preoperative care, intraoperative details, and postoperative care. It helps healthcare professionals maintain accurate and complete records, facilitate communication among the surgical team, ensure patient safety, track the use of equipment and supplies, analyze outcomes, support research and quality improvement efforts, and provide legal documentation if needed.

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No, you can't. With the pdfFiller app for iOS, you can edit, share, and sign operation record sample right away. At the Apple Store, you can buy and install it in a matter of seconds. The app is free, but you will need to set up an account if you want to buy a subscription or start a free trial.

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