Who is responsible for the intra-op records during a surgical procedure?

The responsibility for maintaining intra-op records during a surgical procedure typically falls to the circulating nurse. This role involves overseeing the overall environment in the operating room, ensuring that all necessary supplies are available, and documenting key events during the surgery. The circulating nurse acts as the communication link between the surgical team and external parties, including tracking the patient's status, noting the start and end times of the procedure, recording any medications administered, and keeping an accurate count of surgical instruments and sponges used.

While other roles, such as the surgeon, surgical technologist, and anesthesia provider, contribute significantly to the surgical procedure, they are not primarily tasked with the comprehensive documentation that is essential for proper intra-operative record-keeping. The surgeon focuses on performing the procedure, the surgical technologist assists in maintaining the sterile field and providing instruments, and the anesthesia provider manages the patient’s anesthesia and vital signs. Each of these roles is vital, but the responsibility for detailed intra-op records is specifically designated to the circulating nurse to ensure that all critical information is accurately captured and readily available for post-operative care and legal documentation.