Manual: GI Laboratory Policy and Procedure Manual (Ver 7) External Reference: (TJC PC.03.01.05, RC.02.01.01)
MCN's customizable template, GI Laboratory Nurses' Notes Form, is taken from our GI Laboratory Policy and Procedure Manual. MCN Healthcare's proven policy and procedure templates, competencies and compliance tools have assisted more than 20,000 health care organizations worldwide meet their regulatory compliance goals. Health care organizations around the world utilize MCN's compliant ready templates and workflow process tools to help them meet the latest changes in regulations and standards. Here is some sample content from GI Laboratory Nurses' Notes Form:
| | GI LABORATORY NURSES' NOTES
Patient Name:
Pre-op Assessment Check all applicable boxes
Date:
Patient Identification
q Verbal
q Scheduled
q Add-On
Verification of Procedure Allocation
q Verbal
q Blood Transfusion Consent Form Signed
NPO After Midnight
q Inpatient
Mental/Emotional Status
q Alert
q Agitated
Patient
In Room
Out of Room
Anesthesia
Start
Stop
Procedure
Start
Stop
Limitations
q None
q Other:
Procedure verified before incision/start?
Time-Out
q Yes
Personal Items
Items:
Dispositions:
Comfort Measures Implemented
q Adequate
Transfer to OR Bed
Type of Anesthesia
q ... |
| Second excerpt: |
| | ... Halothane
q Ethane
q Refer to Anesthesia Record
Patient Monitoring: Local Cases
Comments:
Pre-op Diagnosis:
Procedure:
Post-op Diagnosis:
Specimen
1.
2.
3.
4.
5.
6.
Wound Classification
q Clean
q None
q Culture
Implants stents, tubes
Medications/Irrigations Other than Anesthesia
Name
Amount
Route
Time
Patient Response
Signature:
Position for Procedure:
q Arm Board
q Jackknife
q Pad bony prominences
Position Aids:
Positioned by:
ESU Serial #
ESU: Ground Pad Lot #:... |
|