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Table 1 Standard of assessment for perioperative documentation

From: Audit of electronic operative documentation in interventional radiology: the value of standardised proformas

The Standard

Pre-operative

Name and signature of operator(s);

Documentation of type of consent obtained (verbal vs written);

Record of WHO safety checklist completed.

Intra-operative

Name and quantity of medications used;

Site of puncture recorded;

Presence/Absence of complications recorded;

Management of complications recorded (if any).

Post-operative

Plan for post-operative vital monitoring recorded;

Required duration of bed rest recorded;

Puncture site instructions recorded;

Distal pulse monitoring instructions recorded;

Requirements for anti-coagulation recorded;

Requirements for post-operative oral intake recorded;

Follow-up plans recorded.