Another surgical information that goes into the medical record is the postsurgical care plan to surgical patients. A postsurgical care plan is important for discharge planning and future planning are based on medical and nursing care plans after surgery. The Joint Commission International (JCI) Standard ASC.7.4 also emphasises the importance for such a plan through its statement which reads, “Patient care after surgery is planned and documented.”
As each surgical patient’s postsurgical medical and nursing care needs usually differ, immediate postsurgical care is planned and includes medical, nursing, and others as indicated by the patient’s defined needs. The postsurgical care plan which can begin before surgery based on the patient’s assessed needs and condition, includes the level of care, care setting, follow-up monitoring or treatment, and need for medication.
The postoperative phase (which is each surgical patient’s postsurgical care period) continues until the patient is released from the surgeon’s care. When the client is discharged from the postanesthesia care unit (PACU), the surgeon will later decide the next level of care and the care setting for the patient. The surgeon documents in the postsurgical plan whether the patient goes either directly to an inpatient hospital bed or to the outpatient ambulatory unit for observation or to discharge the patient to the patient’s home.
The postsurgical care plan will also contain information on follow-up monitoring of the postoperative patient’s return to normal (baseline) respiratory function and cardiopulmonary function and the patient is free from signs of a wound infection within 72 hours after surgery.
Postoperative discomforts like pain – which is usually most severe immediately after the patient’s recovery from anaesthesia, postoperative nausea, urinary retention, postoperative constipation, postoperative flatus all require treatment and need medication. The treatment(s) and medications form part of the postsurgical care plan documentation.
A Health Information Management (HIM) / Medical Records (MR) practitioner will find among the contents of a medical record for a patient who had undergone surgery, a postsurgical plan(s) documented in the patient’s medical record by the responsible surgeon or verified by the responsible surgeon by co-signature on the documented plan entered by the surgeon’s delegate. The nursing postsurgical plan of care and when indicated by the patient’s needs, the postsurgical plan of care provided by others are also documented in the patient’s medical record. These are often documented in the progress notes. However, nursing care plans are not usually filed in the permanent patient record. The date and time for each of the plans of care documented in the patient’s medical record are evidence to verify that each planned care was provided and documentation was done within 24 hours of the surgery.
With this post, I believe I have completed posts on anaesthesia care and surgical care which have explicit reference to surgical documentation in a medical record for a patient who undergoes surgery.
Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA
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