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Operating on Bilateral Organs

Operations on bilateral organs pose special documentation problems. While it is impossible to defend operating on the wrong side, it does happen. The risk managers for the Copic insurance company have developed a six-step procedure for ensuring that the operation is carried out on the correct side:

The physician should record the correct side in the admission note to the hospital;

The nurse's admission note should list the correct side;

If applicable, the radiology report or x-rays themselves should be available in the operating room;

The anesthesiologist should be asked to record the proper side in the anesthesia note;

The circulating nurse should ask the patient before induction and record the results in the operative log; and

The patient's consent form should list the correct side for the procedure. If any of the six does not agree, then stop the surgery.

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