TheatrePracticeStandardsGeneric1

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Generic Theatre Standard No 02 - Operating Theatre Record Keeping and Documentation at RCHT Standard Statement: All staff are aware of the required standards for documentation and take responsibility for all their individual documentation of information Policy On Clinical Record Keeping on document 1. General Considerations • Under the Public Records Act 1958 (National Archives, 2009), all NHS employees are responsible for any records that they create or use in the course of their duties. Thus any records created by an employee of the NHS are public records and may be subject to both legal and professional obligations. • The quality of record keeping is a reflection of the standard of professional practice expected of professional practitioners (AfPP, 2007). • The record must be (NMC, 2009): • Factual, consistent and accurate • Recorded/written as soon as possible after the event has occurred, providing current information on the care and condition of the patient • Recorded/written clearly and in such a manner that the text cannot be erased, written in a manner that any alterations or additions are dated, timed and signed such that the original can still be read clearly, with the signature printed alongside the first entry • Not include abbreviations, jargon, meaningless phrases, and irrelevant speculation • If written, recorded in black ink only so that photocopies are readable • Records made in the operating theatre must adhere to the General Caldecott Principles (HSC, 1998) on confidentiality: • Justify the purpose(s) • Don’t use patient-identifiable information unless it is absolutely necessary • Use the minimum necessary patient identifiable information • Access to patient-identifiable information should be on a strict need-toknow basis • Everyone with access to patient-identifiable information should be aware of his or her responsibilities. • Understand and comply with the law Theatre Practice Standards - Generic Page 10 of 105
• All entries into the health record, including amendments, should be clearly dated, timed, signed and the designation of the person making the entry should be clearly recorded. • The Theatre Manager will retain copies of signatures of all healthcare professionals who make entries in healthcare records, together with the professional's registration number (NMC or HPC). The register of signatures will be reviewed and updated annually. • All electronic reporting will be traceable via the ‘login’ system. 2. Theatre Register • The theatre register will record: • Procedures which were undertaken (both surgical and the type of anaesthetic) • The names of surgeon and anaesthetist and a list of support staff • The name of the scrub and circulating practitioner • The time each patient entered and left theatre • The patient’s name, date of birth, sex, NHS number, scrub and circulating practitioner, implanted materials and any untoward incidents • Details of any implants • Details of untoward events 3. Swab Instrument and Needle Count • The Swab instrument, needle and sharps count record must be made in the Theatre Register, electronically and in the patient’s record. 4. Recording of implant/prosthesis • A prosthesis used for hip of knee surgery should be recorded in accordance with the National Joint Registry (NJR) guidelines and the Consumer Protection Act (SI, 1987). • Information recorded will include: • Manufacturer • Product source • Type of implant/prosthesis • Code number • Batch/lot number • Size • Sterilisation date/date of manufacture • Expiry date • Any amendments or adaptation made • Tracking and traceability • Please read the National Joint Registry: An Introduction to NJR IT systems Theatre Practice Standards - Generic Page 11 of 105
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Page 4 and 5: MEMBERSHIP OF THE WORKING PARTY Dr
Page 6 and 7: SECTION I - SUMMARY AND RECOMMENDAT
Page 8 and 9: SECTION III - INTRODUCTION Patients
Page 10 and 11: purchase these services. They must
Page 12 and 13: SECTION VI - PREPARATION FOR THE TR
Page 14 and 15: A patient who remains hypotensive d
Page 16 and 17: A patient who has been made physiol
Page 18 and 19: 4. Other equipment • suction •
Page 20 and 21: important to involve those who take
Page 22 and 23: REFERENCES 1. Association of Anaest
Page 24 and 25: APPENDIX II TRANSFER CHECKLIST FOR
Page 26 and 27: 21 Portland Place, London W1B 1PY T
Page 28 and 29: Storage of Drugs in Anaesthetic Roo
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Page 32 and 33: 6.2. Overall performance against th
Page 34 and 35: • Clean theatre clothing should b
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Page 40 and 41: • Please read NJR Manual and Trai
Page 42 and 43: 13. Positioning of the Patient •
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Page 46 and 47: Example of Environmental Theatre Cl
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• The labelled container must be
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• Staff Responsibility • All st
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• It is the responsibility of the
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6. Induction of anaesthesia • See
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4. Time Out - Before start of surgi
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• The registered anaesthetic prac
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• The Senior Surgeon/Operating Cl
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Generic Theatre Standard No 16 - St
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3. Planned over-running sessions
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• Advice should be obtained from
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8. Harassment and Bullying • Dign
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Appendix 1. Governance Information
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Appendix 2. Initial Equality Impact
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