Health Information Management (HIM) / Medical Records (MR) practitioners need to be aware that a medical record for a patient who had undergone surgery, has his or her monitoring findings of their physiological status written in his or her medical record. A patient’s physiological status is continuously monitored during (intraoperative) and immediately after surgery (postoperative), appropriate to the patient’s condition and the procedure performed.
I think HIM/MR practitioners also need to know why a patient’s physiological status is continuously monitored during and immediately after surgery and what is documented into the medical record, as I have outlined below.
Results of monitoring trigger key intraoperative decisions as well as postoperative decisions, such as return to surgery, transfer to another level of care, or discharge.
The focus of intraoperative care is to promote the patient’s achievement of expected intraoperative outcomes directed at placing the patient in a safe environment free from injury. The Operating Room (OR) team monitors the patient throughout the surgical procedure for complications, for example the patient’s fluid and electrolyte balance is maintained.
Before the client is transferred to the Post-Anaesthesia Care Unit (PACU), evaluation of the patient is based on reassessment of findings for the patient during surgery. The specific data on the achievement of patient outcomes in the intraoperative phase is documented on the OR record, i.e. the Operative Record.
The postoperative phase continues until the patient is released from the surgeon’s care. After surgery, the on-going care is directed toward restoring physiological functioning, promote healing, and prevent complications and return the patient to the preoperative health status. The patient is monitored for (i) respiratory status for example, one postoperative assessment finding on airway and respiratory status shows the patient is able to expel an oral airway and exhibits return of gag reflex after the patient is extubated, (ii) circulatory status, (iii) neurologic status (monitoring the patient’s level of consciousness), (iv) fluid and metabolic status (monitoring the patient’s (a) gastrointestinal system– for example, with abdominal surgery, abdominal distension to detect internal haemorrhage is monitored and (b) genitourinary system – for example, assessment for bladder distension, (v) level of discomfort or pain, and (vi) wound management.
Monitoring information guides medical and nursing care and identifies the need for diagnostic and other services.
Physiological monitoring during intraoperative and postoperative phases by the OR team is related to the same requirement for physiological monitoring during anaesthesia, which you can refer to from the earlier post Check your medical record for patient monitoring during anaesthesia (this link will open in a new tab of your current browser window).
Physiological monitoring during intraoperative and postoperative phases is documented in the postoperative progress notes and the Operative Record. The surgeon or nurse is responsible for documenting the medical and nursing aspects of physiological status monitoring.
If your hospital is seeking a hospital accreditation status for example the Joint Commission International (JCI) accreditation status or already JCI accredited or plans for a JCI re-survey, then it is only normal to comply with the JCI Standard ASC.7.3 which states “Each patient’s physiological status is continuously monitored during and immediately after surgery and written in the patient’s record.”
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA