These are the conventions used at UNC in charting the OR Record. Scroll down, or jump specifically to: Upper Left Section, Medication Area, Graphic Area, Unlabeled Cells Below Graph, Table of Other Parameters, or Procedure Notes.

-Upper Left Section

• Fill in all boxes, including HEIGHT
• Blank lines: for PAST MED HX and relevant LABS

• Gases (O2, N20, Air)
• Volatile agents
• Induction agents
• Maintenance drugs (e.g., opioids, muscle relaxants)
• Infusions: chart rate of administration for all meds, including drips run through "dial-a-flow" (chart approximate rate from control dial)
• Single-administration drugs at bottom (e.g., antibiotics, steroids)

• Track at least HR, and BP
• In addition, consider tracking BIS (as a line)
• Differentiate between NIBP and ABP measurements
• At top, write in hemodynamic parameters (PAS/PAD, SvO2, PCWP/CVP, CO/SVR)
• Near bottom, ACT
• At bottom, mark events with numbers (corresponding to notes), and mark times of ABG draws with asterisks (*) or numbers

• ABGs (pH/PCO2, PO2/BB, Na/K/I Ca, Gluc/Hgb)
• Position, level of sensation (spinals and epidurals), documentation of pressure point and/or mental status checks

• NMT is usually for train of four (chart number of twitches)
• Minute vent: chart RR x TV
• IV access: list IVs (size, type, location), except for cases where fluids are recorded separately (e.g., liver transplant). Chart fluids periodically as amount given since last charted/running total for that IV (e.g. 200/200, then 300/500, etc.)
• UOP: Chart urine output q30-60min as amount measured since last charted/running total (e.g. 50/50, then 100/150, etc.)
• EBL: Chart same as UOP

• All notes should include: indication, position, method of site prep, equipment used (with lot number, expiration date), technique, and medications used. Specific examples below...
• Epidural: Perifix Tray, Lot #123456, Exp 04-2002. For intraop/postop pain. Sitting, betadine x 3, sterile drape. T7-8. Paramedian approach, lido 1% local. 17G Tuohy, 1 pass. LOR (saline) @ 5cm, cath threaded easily to 10cm at skin. Neg paresthesia/CSF/Heme. Sterile dressing. -YOUR NAME
• Brachial Plexus Block: 2" Stimuplex needle. Betadine x 3. Local = mix 30cc mepiv 1% + 30cc 1.5% + HCO3 6cc + Epi 150mcg. Coracoid approach. Local skin wheal --> 2 passes, radial n. @ 0.32 mAmps. 50cc in divided doses, neg aspiration and VSS throughout. - YOUR NAME
• CVC: Arrow 2-lumen, Lot # 987654321-0, Exp 02-2002. Indic-CVP, IV access. T-berg. Betadine x 3, sterile drape. Middle approach, Seldinger technique: 22G finder -> 18G cath -> wire -> cath out -> nick -> dilator, then out -> cath, to 16cm -> wire out. +blood return x2; flushed with hep-saline. Sutured, sterile dressing. +CVP trace. - YOUR NAME