JHH OR and Procedure Tracer

This document outlines comprehensive guidelines for surgical and procedural documentation in healthcare settings. It covers essential requirements for patient safety and medical record keeping, including pre-operative documentation, H&P updates, informed consent procedures, anesthesia protocols, and post-operative documentation standards. The guidelines detail specific timeframes for documentation completion, safety protocols such as site marking and time-out procedures, medication handling requirements, and post-anesthesia evaluation criteria. It also includes requirements for immediate and detailed post-operative notes, discharge documentation, and equipment handling procedures. These standards ensure compliance with healthcare regulations while maintaining patient safety and proper medical record documentation.

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