How to Choose an Operating Room Charting System

Doctors and operating room staffers must document everything that's done in an operating room theater, not only for insurance and billing purposes but to chart and analyze quality patient care and care-giving processes. Charting in the operating room has advanced from nurse's notes to oral dictation to video-recording systems. Today, computerized charting systems make the job easier, more efficient and more accurate.

Instructions

• 1

  Compare and analyze computer charting systems that are compatible with your hospital's current health informatics software and health information records system. The ability to integrate an operating room system into the health care provider's mainframe computer system for best use of inter-staffing and department needs helps provide seamless and consistent care within a hospital environment.

• 2

  Choose a surgical charting system that meets the needs of the Joint Commission, a health care accreditation organization that promotes health care standards and patient safety in all medical care fields, or the Surgical Care Improvement Project, (SCIP), an organization focusing on improvement of surgical safety and care. Charting systems in the operating room will allow more in-depth analysis of procedures performed by a hospital as well as offer up-to-date information or changes in a patient's condition before, during and after surgery and allows health care staff to follow that patient through every step of the process.

• 3

  Select an operating room charting system that allows providers to input information for both ambulatory services and inpatient hospital procedures. Such documentation can range from scheduling appointments to offering input data for anesthesia during surgery to step-by-step documentation of the entire surgical procedure.

• 4

  Research charting systems that enable surgical suite staff to input supplies, tools and equipment used in the operating room during all surgical procedures. Such data may help hospital administrations to streamline services, ensure adequate supplies and track costs per procedure. An operating room charting system can help surgical theater staff to determine more precisely the necessary equipment needed for specific procedures and operations, cutting down on waste, suggests the Med Compare website, an online resource for medical professionals and providers.

• 5

  Choose an operation room charting system that allows nursing staff and other medical providers to chart and track fluids, medications and allergies to any drugs, so information can be viewed at any time during the pre-operative, surgical, and post-operative time frames to reduce errors in patient care. Tracking anesthesia types, duration and dosage can be immediately recorded into the system, offering greater anesthesia management services, according to the website of McKesson, a medical tools and technology supplier in the United States and abroad.

• 6

  Devise or select an operating room charting system that can interface with the medical records or health information department and all disciplines involved in that patient's care within the facility and allow for physician's dictation within its system interface.