Consents
How long is a consent good for?
30 days
How long is a H&P good for?
30 days
Does the hand-off require patient involvement?
If the patient is alert and oriented, it is best practice to involve the patient
When is the time-out performed?
Immediately before incision
The procedure site is initialed by who?
The surgeon
or the mid-level (NP/PA) IF they are participating in the procedure
What is required on an anesthesia consent?
The anesthesiologist's first and last name must be printed at the top of the consent
True or False?
Each time-out performed must be documented in the chart.
TRUE
Who is required to be present during hand-off before going to the OR?
Pre-op nurse, OR nurse, and anesthetist (unless anesthesia is not required for the case. ex: local case)
Where should the procedure name be read from while conducting a time-out?
The surgical consent
When is a site marking required?
When the procedure involves laterality, multiple structures, or multiple levels
What four consents would you look for when getting your patient from pre-op?
General Consent (burrito)
Surgical Consent
Anesthesia Consent
Blood Consent
What two places can you find a patient's H&P?
The front of the patient's chart and in Cerner under document viewing
When is hand-off documented in Cerner in the Intraop Record?
Any break 30 minutes or longer. Always for permanent relief
Who needs to be involved in the time-out?
Every team member
True or false?
"Possible" cases involving laterality do not need to be marked.
True -- Only mark definite consented procedures
True or false?
Only approved abbreviations are permitted on a surgical consent
FALSE
What should be included on each document in the patient's chart?
A Patient Label
What tool is used to structure hand-offs?
Cerner Hand-Off Tool & Hand-Off Paper Tools
When should a time-out be restarted?
If there is an interruption or a discrepancy
If the patient cannot be marked due to practicality, what should be done?
A unique band should be placed on the correct side and initialed by the surgeon with the procedure written on the band
If corrections are made to a consent, what is the required?
A single line must be put through the incorrect writing
Surgeon's initials, patient initials, time, and date of update should be written next to the correction
Patient arrives today for 0730 surgery, and the H&P was updated yesterday at 1130.
Is the H&P update still acceptable?
No. Why?
What steps would you take if you notice a discrepancy between your patient's arm band & their patient label on the pharmacy/intraop med sheet?
Alert chain of command and collaborate with your pre-op nurse to notify Cerner and Registration of the discrepancy. Do not roll with your patient until discrepancy is completely resolved.
When do you need an additional time-out? (3 answers)
Position change
Surgeon change
Surgeon leaves room and returns
How should you mark a patient for a Right Colectomy?
Trick question!
No marking is required