Intraoperative

Medication documentation during procedures

Saduf Ashfaq's picture

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Hello everyone,

We recently had an issue where a provider used our usual bronch order set to order prn fentanyl and midazolam:

- Fentanyl 25mcg iv Q3min PRN for moderate sedation (only as directed by physician)
- Midazolam 1mg iv q2min PRN for moderate sedation only as directed by physician)

This procedure was done on an ICU unit. Since this wasn't actually done in a designated periop area, it was a nurse who was administering the medications (not a provider), but these were documented in OpTime and not on the MAR under their respective orders.

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