<results version='1.05' timeZone='-0500' >
<documents total='1' >
<document>
<category value='SR' />
<clinicians>
<clinician code='520647004' name='MCCARTHY,MOIRA C' role='A' taxonomyCode='203BS0130Y' providerType='Physicians (M.D. and D.O.)' classification='Physician/Osteopath' specialization='Surgery, Otorhinolaryngology &amp; Facial Plastic Surgery' service='OIFO BAYPINES TEST LAB ' />
<clinician code='520646984' name='REVER,MICHAEL' role='S' dateTime='3150824.170413' signature='MICHAEL REVER ' taxonomyCode='203BS0130Y' providerType='Physicians (M.D. and D.O.)' classification='Physician/Osteopath' specialization='Surgery, Otorhinolaryngology &amp; Facial Plastic Surgery' service='OIFO BAYPINES TEST LAB ' />
</clinicians>
<content xml:space='preserve'>
 LOCAL TITLE: NURSE INTRAOPERATIVE REPORT
STANDARD TITLE: SURGERY PROGRESS NOTE
DATE OF NOTE: AUG 20, 2015@16:04     ENTRY DATE: AUG 20, 2015@16:06:57
      AUTHOR: MCCARTHY,MOIRA C     EXP COSIGNER:
     URGENCY:                            STATUS: COMPLETED
     SUBJECT: Case #: 30928

Operating Room:  ORC                    Surgical Priority: EMERGENCY

Patient in Hold: AUG 20, 2015  13:30    Patient in OR:  AUG 20, 2015  16:04
Operation Begin: AUG 20, 2015  16:06    Operation End:  AUG 20, 2015  16:06
Surgeon in OR:   AUG 20, 2015  14:01    Patient Out OR: AUG 20, 2015  16:06

Major Operations Performed:
Primary: colonoscopy

Wound Classification: CLEAN
Operation Disposition: ICU
Discharged Via: ICU BED

Primary Surgeon: MCCARTHY,MOIRA C       First Assist: REVER,MICHAEL
Attending Surgeon: MCCARTHY,MOIRA C     Second Assist: REVER,MICHAEL
Anesthetist: FORREST,ZACHARY            Assistant Anesth: REVER,MICHAEL

Other Scrubbed Assistants:
  REVER,MICHAEL

OR Support Personnel:
  Scrubbed                              Circulating
  N/A                                   N/A

Preop Mood:       RELAXED               Preop Consc:    ALERT-ORIENTED
Preop Skin Integ: INTACT                Preop Converse: N/A

--- Time Out Checklist ---
Confirm Correct Patient Identity: YES
Confirm Procedure To Be Performed: YES
Confirm Site of the Procedure, Including Laterality: YES
Confirm Valid Consent: YES, i-MED
Confirm Patient Position: YES
Confirm Procedure Site has been Marked Appropriately and that the Site of the
 Mark is Visible After Prep and Draping: YES
Pertinent Medical Images Have Been Confirmed: YES
Correct Medical Implant(s) is Available: YES
Availability of Special Equipment: YES
Appropriate Antibiotic Prophylaxis: YES
Appropriate Deep Vein Thrombosis Prophylaxis: YES
Blood Availability: YES
Checklist Comment:
   testing surgery 08242015 3

Time-Out Document Completed By: REVER,MICHAEL
Time-Out Completed: AUG 24, 2015@13:35

Preop Surgical Site Hair Removal by: N/A
Surgical Site Hair Removal Method: SHAVING
  Hair Removal Comments:
   testing 08242015 6 (it would not let me select flamethrower!)

Surgery Position(s):
  SUPINE                                Placed: AUG 20, 2015  16:04

Restraints and Position Aids:
  SAFETY STRAP                      Applied By: N/A

Material Sent to Laboratory for Analysis:
Specimens:
  testing surgery 08242015 1
Cultures:
  testing surgeries 08242015 2

Anesthesia Technique(s):
  GENERAL

Possible Item Retention:    YES
Sponge Final Count Correct: YES
Sharps Final Count Correct: YES
Instrument Final Count Correct: YES
Wound Sweep:                YES
Wound Sweep Comment:
   testing surgery 08242015 4
Intra-Operative X-Ray:      YES
Intra-Operative X-Ray Comment:
   testing surgery 08242015 5
Counter:                  YANNI,CATHERINE
Counts Verified By:       REVER,MICHAEL

Packing:  VASOLINE

Blood Loss: 99 ml                       Urine Output: 101 ml

Postoperative Mood:           RELAXED
Postoperative Consciousness:  DELIRIOUS &amp; RESTLESS
Postoperative Skin Integrity: INTACT
Postoperative Skin Color:     DEEP BROWN

Immediate Use Steam Sterilization Episodes:
   Contamination:                       0
   SPS Processing/OR Management Issues: 0
   Emergency Case:                      0
   No Better Option:                    0
   Loaner or Short Notice Instrument:   0
   Decontamination of Instruments Contaminated During the Case: 0

Nursing Care Comments: NO COMMENTS ENTERED

/es/ MICHAEL REVER

Signed: 08/24/2015 17:04
for MOIRA C MCCARTHY

</content>
<documentClass value='SURGICAL REPORTS' />
<encounter value='2205684' />
<facility code='442' name='CHEYENNE VAMC' />
<id value='1804700' />
<localTitle value='NURSE INTRAOPERATIVE REPORT' />
<loinc value='29752-3' />
<nationalTitle name='SURGERY PROGRESS NOTE' />
<nationalTitleSubject name='SURGERY' />
<nationalTitleType name='PROGRESS NOTE' />
<referenceDateTime value='3150820.1604' />
<status value='completed' />
<subject value='Case #: 30928' />
<type value='SR' />
</document>
</documents>
</results>