Staff IP Encounter Report MRN DOB Sex F Adm7232013 DC7272013 SURGICALPROCEDURAL

Staff ip encounter report mrn dob sex f adm7232013

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Staff
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IP Encounter Report MRN: DOB: Sex: F Adm:7/23/2013, D/C:7/27/2013 SURGICAL/PROCEDURAL INFO ON ENCOUNTER (continued) Electro Surgery Units (continued) ESU Type ESU Blend Setting Mode Pad Loc Laterality Coag Set Cut Set Applied By ar G. Tourniquets Warming Devices Device Type Device Setting Area Lateralit y Temp Applied By K-Thermia K THERMIA CDH 10772 - #10 Medium - 38 Celsius Full body Bilateral pt temp monitored by anesthesia Implants Specimens None PNDS Information (MR # Printed by [103311] at 10/11/13 10:27 AM Page 54 Yes The patient is free from signs and symptoms of injury caused by extraneous objects. (O2) Yes Applies safety devices. (I11) Yes Records devices implanted during the operative or invasive procedure. (I112) Yes Uses supplies and equipment within safe parameters. (I122) Yes Maintains continuous surveillance. (I128) Yes Implements protective measures prior to operative or invasive procedure. (I138) Yes Evaluates for signs and symptoms of physical injury to skin and tissue. (I152) Yes Confirms identity before the operative or invasive procedure. (I26) Yes Implements protective measures to prevent injury due to laser sources. (I73) Yes Implements protective measures to prevent skin or tissue injury due to thermal sources. (I76) Yes Implements protective measures to prevent skin/tissue injury due to mechanical sources. (I77) Yes Manages specimen handling and disposition. (I84) Yes Performs required counts. (I93) Yes Performs venipuncture. (I95) Yes The patient is free from signs and symptoms of chemical injury. (O3) Yes Implements latex allergy precautions as needed. (I139) Yes Evaluates for signs and symptoms of chemical injury. (I36) Yes Implements protective measures to prevent skin and tissue injury due to chemical sources. (I75) Yes The patient is free from signs and symptoms of injury related to positioning. (O5) Yes Verifies presence of prosthetics or corrective devices. (I127) Yes Evaluates for signs and symptoms of injury as a result of positioning. (I38) Yes Identifies physical alterations that require additional precautions for procedure-specific positioning. (I64) Yes Positions the patient. (I96) Yes The patient is free from signs and symptoms of injury related to transfer/transport. (O8) Yes Transports according to individual needs. (I118) Yes Evaluates for signs and symptoms of skin and tissue injury as a result of transfer or transport. (I42) Yes The patient receives appropriate medication(s), safely administered during the perioperative period. (O9) Yes Verifies allergies. (I123) Yes The patient is free from signs and symptoms of infection. (O10) Yes Assesses susceptibility for infection. (I21) Yes Classifies surgical wound. (I22) Yes Implements aseptic technique. (I70) Yes Initiates traffic control. (I81) Yes Manages culture specimen collection. (I83) Yes Minimizes the length of invasive procedure by planning care. (I85) Yes Monitors for signs and symptoms of infection. (I88) Yes Performs skin preparations. (I94) Yes Protects from cross-contamination. (I98) Yes The patient is at or returning to normothermia at the conclusion of the immediate postoperative period. (O12) Yes Assesses risk for inadvertent hypothermia. (I131) Yes Evaluates response to thermoregulation measures. (I55)
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