The HUC and the Surgical Chart

The Hybrid Chart

The HUC may be required to add additional chart forms to the hybrid patient record when a patient is booked for surgery. These records include:

• Consent form
• Pre-anaesthetic questionnaire
• Anaesthetic record
• OR checklist
• Applicable pre-printed postoperative orders

In addition, the HUC should ensure that the history and physical is on the patient chart prior to surgery, the MARs and any preop testing results are in the chart, and that there are additional patient ID stickers in the chart to label any specimens or additional forms.

e-Chart

The HUC will not need to add physical forms to the e-Chart, however, they may be required to scan patient completed forms into the e-Chart, such as a signed consent form and the pre-anaesthetic questionnaire.

The Post-Operative Chart

Regardless of the type of chart, all documentation should be ready well in advance. It is typical for the porter to arrive on a patient unit 30 minutes prior to the scheduled surgery time to retrieve the patient. This allows for transportation time to the OR, time to review and confirm the procedure with the surgical team prior to the OR, and time for the anaesthetist to administer medication. Following the procedure, the patient will be transferred to the post-anaesthesia care unit (PACU) and then returned to the post-operative unit for recovery. This process typically takes three to four hours from start to finish.

In a hybrid setting, the HUC must review the physical chart for post-operative orders and process them as required when the patient returns to the post-operative surgical unit. In fully electronic or CPOE environments, the physician will enter the post-op orders in the operating room and the HUC will not need to process these.

References

Schwartz, A. J. (2016, June). Anesthetic records: Lesson about ethics and education. Anesthesiology, 124(6).

South Shore District Health Authority. (2007). Documentation: Standards for medical. Nova Scotia Health Policy Office.

Thompson, V. D. (2018). Administrative and clinical procedures for the Canadian health professional (4th ed.). Pearson Canada.