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Operating Room Notes -- any nurses out there???

gwennie17gwennie17 Posts: 2,957
edited 06/11/2012 - 8:37 AM in Back Surgery and Neck Surgery
I know how to obtain operating room notes, and have done so for my two surgeries. I was wondering if there are other reports I should request for my time in the hospital. This would only apply to my fusion as I wasn't there long enough the second time for anything to happen!

Does the nursing staff take notes on each patient? If so, is there any point of requesting them, or are they even available?

Thanks for any information you can provide --



  • Nurses are required to do notes after their shift on their patients. As Eve noted above, you can obtain a copy of them. You can also obtain a copy of your doctor's admission and discharge reports, labs, etc. If you have any concerns about your nursing care, I would get a copy of those notes for your records.

    Hope you have a wonderful day.

    Best to you,

  • Actually something happened the first time the PT came to see me in the hospital. Doing an exercise in bed, I followed her instructions and pressed down with my quad muscle while in bed -- and immediately had the worst pain I'd ever experienced in my life. I am not a screamer, AT ALL, but I could not control myself...the pain was that bad. The nurse had to give me something in my IV to calm me down...and to this day, I have nerve pain in the front of my thigh. I never had it prior to the day after my fusion!

    I have decided to go to CA to meet with a surgeon who invited the MRN - neurography procedure to see if they can figure out the source of my nerve pain. He requested records from both my surgeries....and I thought it might be interesting to see if there is any record of this PT incident.

    Thanks for your replies, ladies. I see a few of us are up at this weird hour. I had a nerve block this morning at 8:45 and the steroid gives me such a buzz that I am awake at least 24 hours, sometimes longer.

  • Gwennie
    PT has to document any treatment they do just as anyone giving you care. Most is on computer now or is written on a progress note.
  • Post removed by moderator paulgla. Inappropriate.
  • You might have to specifically ask for nurses', physical therapy, respiratory, etc. notes including the MAR(medication record.) One thing to know-if the PT made a mistake, she should have filled out an internal incident report and you do NOT have access to internal incident reports. They cannot even be legally forced to provide them.
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