Authors

1Mª Reyes Carrión Camacho, 2Ana Ron Vaz, 2Laura García Mera, 2Manuel Calzón Morilla

Position

¹Máster en Ciencias de la Salud (MCs). Enfermera. Unidad de Gestión Clínica Bloque Quirúrgico Hospital General. Hospital Universitario Virgen del Rocío, Sevilla (España). ²Enfermera/o. Unidad de Gestión Clínica Bloque Quirúrgico Hospital General. Hospital Universitario Virgen del Rocío, Sevilla (España).

Contact address

Mª Reyes Carrión Camacho. Avenida Emilio Lemos, 7, 4º A. 41020 Sevilla.

Contact email: rcarrion@terra.es

Abstract

When surgical treatment must be addressed, the patient is attended by different professionals in different settings: outpatient anesthesia unit, hospitalization, surgical area and post-anesthesia recovery room. This “route” is a security risk for the surgical treatment at each leg of the route, since communication between units and between care teams at the time of the transfer may not include all essential information or be a misinterpretation of it, causing a "breach or gap" in communication and therefore potentially serious disruptions in the continuity of care, inappropriate treatment and potential harm to the patient. This situation highlights the need for patient data and progress notes to be recorded in one single document and under quality standards that must be common to any type of record. To produce the records factors such as time spent in its completion, information on the care provided and utility of it in terms of impact on communication, safety and continuity of patient care should all be taken into account. The present article aims to show and share the work to develop a “surgical route care record”, designed and structured to reflect each and every step of the nursing process, unifying the care provided by the nursing team of all the units where the patient has been looked after in the perioperative process. To develop a registry of these characteristics provides a complete picture of the care provided to patients requiring surgical treatment, in order to ensure continuity and safety in their treatment.

Keywords:

Care registry; perioperative caresurgical area

Versión en Español

Título:

Registro de cuidados: ruta quirúrgica para un bloque quirúrgico