I am revising the pacu flowsheet and would like to know what the exact requirements for documentation are. Are there any samples available? I recently purchased the new opana standards but it does not specify exactly what is required for documentation.
Thanks
Elaine
About Me
- OPANA Ontario Perianesthesia Nurses Association
- Toronto, Ontario, Canada
- OPANA is a nursing association dedicated to the improvement of perianesthesia nursing standards.
1 comment:
In the OPANA standards under standard 5, there is a list of data that should be included on the PACU patient chart:
* type of procedure performed
* type of anesthetic or sedative given
* medications given
* fluid and/or blood loss
* complications
The perianesthesia nurse is to perform a systematic and continuous patient assessment, ensuring that all data are collected, documented and communicated.
These are guidelines that are implemented in accordance with the facilities approval. The College of Nurses of Ontario also is a resource for documentation guidelines; documenation is clear, concise, timely, & accurate.
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