The basic medical documentation in the operating room and dressing room nurse

August 12, 2017 17:50 | Paramedic

Documentation operation unit

1. Operating magazine.

2. Journal of Blood Transfusion.

3. Magazine drug registration.

4. Magazine bacteriological control.

5. drug extract Magazine, solutions and products.

6. Notebook control presterilizing cleaning.

7. Survey magazine.

8. Book Accounting sterilization (if sterilization is carried out in the operating unit).

9. The log areas for histological examination.

10. Journal directions on bacteriological examination.

11. The book accounting dressing.

12. Schedule of general cleanings.

operational log

Fill immediately after the operation is completed.It notes Namethe sick, the year of his birth, the number of medical history and the House, type of anesthesia, the diagnosis, the name of the operation and its short description, the time of the operator and his assistants names, surnames and anesthesiologist anesthetic sisters, as well as the name of the operating nurse.Be sure to put the date of the transaction and a list of participating.

blood transfusion Journal

Fill in the event that the patient in time (before or after) surgery, blood transfusions.Fill out under the supervision of a doctor who is responsible for a blood transfusion.Indicate the date, time, blood transfusion, name, blood group and Rh factor of both the donor and the recipient;which account for a blood transfusion, the purpose of blood transfusion (ie, diagnosis and indications for transfusion), the amount of blood transfused, samples of individual and biocompatibility;as well as a graph of transfusion complications of blood transfusion.This magazine fills nurse separating blood transfusion under guidance of a doctor, and in the absence of separation and post - operating nurse.


drug registration Counts in this magazine is filled with the standard scheme adopted in all hospitals: Namepatient completely, the year of his birth, the number of stories of disease and the Chamber, the diagnosis, the name of the drug, the dose and route of administration;signature of a doctor appointed narcotic drug, and a nurse, injects.

Journal bacteriological control sterility

Bacteriological laboratory of sanitary and epidemiological stations and disinfection carried out bacteriological control at least 2 times a year;bacteriological laboratories of medical institutions controlled hygienic conditions (contamination of various objects and air) 1 once a month, and sterility control instruments, dressing material, surgical linen, the surgeon's hands and the skin of the surgical field - 1 time per week.

list of facilities subject to bacteriological control.

1. Operating:

• desktop anesthesiologists;

• the operating table;

• vacuum pump hose;

• oxygen hose fittings;

• washes hands with everyone involved in the transaction;

• Skin surgical field.

2. dressings:

• couch for dressings;

• towel staff hands;

• toothbrush on the sink;

• bathrobe nurses;

• Medical worker table;

• inner surface of the refrigerator to store medicines.

Sampling in sterile containers in compliance with strict aseptic technique just before the surgery is performed operating nurse under the supervision of personnel of the bacteriological laboratory.The results of bacteriological control sterility logged.

5. drug extract Magazine, solutions and preparations (requirements in the pharmacy).

Fills the elder sister of the operating head of the department signed in two copies, resulting in a list of required solutions, alcohol, drugs and their quantity.

6. Log monitoring presterilizing cleaning.

Filled identical to that described in the chapter "Record keeping in the surgical department."

7. Survey magazine.

kept by the eldest sister operating.It is a notebook with numbered pages, which lists all the equipment in the operating theater: the operating table, lamps, stools, couches, etc.

8. Book Accounting sterilization.

Currently, sterilization is carried out centrally.Operating room nurse spends presterilizing clearing and lays in NIRS instruments and dressings, which are then fed into the operating room sterile.In some small medical offices sterilization is carried out by the operating unit.In this case, give birth to a notebook for sterilization control, which indicate the type of sterilization, temperature, exposure (the exposure time), as well as the name of the sterilization facility.

9. directions Magazine for histological examination.

Fills scrub nurse under a physician's guidance.It indicates the date of the direction, namethe sick, the year of his birth, the number of chambers and medical history, diagnosis, localization of an organ or tissue from which the objects are taken for the study, the name of the surgeon.

10. According to the same form filled directions log for bacteriological examination (inoculation of the wound).