Basic medical documentation in the operation of an operating and dressing nurse

Documentation of the operating unit

1. Operational log .

2. Journal of blood transfusion.

3. The register of narcotic substances.

4. Journal of Bacteriological Control.

5. Journal of discharge of medicinal substances, solutions and preparations.

6. Control book for pre-sterilization cleaning.

7. Inventory log.

8. Notebook for sterilization accounting( if sterilization is carried out in the operating unit).

9. Log of registration of directions for histological examination.

10. Journal of referrals to bacteriological research.

11. The book of dressing material registration.

12. Schedule of general cleaning.

Operational Journal

To be filled immediately after the end of the operation. It is noted by the name.patient, year of his birth, medical history and room number, type of anesthesia, diagnosis, the name of the operation and its brief description, the time, surnames of the operator and his assistants, the names of the anesthesiologist and anesthesia nurse, and the name of the operating nurse. Be sure to put the date of the operation and the murals of those participating in it.

Journal of blood transfusion

Fill in if the patient was transfused during( before or after) the operation. They are filled under the guidance of a doctor responsible for blood transfusion. Indicate the date, blood transfusion time, surname, blood group and Rh factor of both the donor and the recipient;what is the blood transfusion, the purpose of blood transfusion( i.e., diagnosis and indications for transfusion), the amount of blood transfused, samples for individual and biological compatibility;as well as a graph on transfusion complications in blood transfusion. This journal is filled in by the nurse of the blood transfusion unit under the guidance of a doctor, and in the absence of this department and position - the operating nurse.

Journal of Narcotic Drugs

The columns in this journal are filled in according to the standard scheme adopted in all medical institutions:the patient completely, the year of his birth, the number of case histories and the ward, the diagnosis, the name of the drug, its dose and mode of administration;the signature of the doctor who prescribed the narcotic drug and the nurse who injected it.

Journal of bacteriological sterility control

Bacteriological laboratories of sanitary-epidemiological and disinfection stations carry out bacteriological monitoring at least twice a year;bacteriological laboratories of medical institutions monitor the sanitary-hygienic regime( dissemination of various objects and air) once a month, and control of the sterility of instruments, dressing materials, surgical linen, hands of the surgeon and the skin of the operating field - once a week.

List of objects subject to bacteriological control.

1. Operating:

• anesthesiologists desk;

• operating table;

• vacuum pump hose;

• Oxygen piping hose;

• flushing from the hands of all involved in the operation;

• skin of the operating field.

2. Dressing:

• a couch for dressings;

• Hand towel for the staff;

• brush on the sink;

• a nursing gown;

• working medical table;

• the inside of the refrigerator for storing medicines.

Sampling in sterile tanks in compliance with the strictest rules of asepsis immediately before the operation is performed by the operating nurse under the guidance of a bacteriological laboratory employee. The results of bacteriological sterility control are recorded in the log.

5. Journal of discharge of medicinal substances, solutions and preparations( requirements in the pharmacy).

Filled by the senior operating sister with the signature of the head of the department in two copies, listing the necessary solutions, alcohol, drugs and their quantity.

6. Journal of the control of pre-sterilization cleaning.

To be completed identically described in the chapter "Maintaining documentation in the surgical department".

7. Inventory log.

Stored in the senior operating sister. It is a notebook with numbered sheets, where all the equipment in the operating unit is listed: an operating table, lamps, stools, couches, etc.

8. Notebook for sterilization.

Currently, sterilization is carried out centrally. The operating nurse performs pre-sterilization cleaning and lays instruments and bandages in the beads, which then enter the operating room as sterile. In some small treatment units, sterilization is performed by the operation unit. In this case, a notebook is created to control the sterilization, where the type of sterilization, the temperature regime, the exposure( holding time), and the name of the sterilization object are indicated.

9. Journal of the directions for histological examination.

Filled by the operating nurse under the guidance of a physician. It indicates the date of the referral,patient, year of his birth, room numbers and medical history, diagnosis, localization of the organ or tissue, where the objects for the study are taken, the name of the surgeon.

10. The log of registration of directions for bacteriological examination( seeding from a wound) is filled in the same form.