OR nurses are held responsible for ensuring surgeons properly update H&P notes, but lack the authority or tools to enforce timely and correct documentation, leading to blame and potential incident reports.

Workarounds Described

• Charge nurse manually reviews H&P note and tries to fix it after patient already in OR
• Nurse responsible for checking surgeon's note placement and risking incident report

Implied Software Gaps

• Automated H&P compliance check before surgery with clear accountability
• System to prevent old notes from being reused without proper date update

PreOp ChartGuard

An automated compliance check integrated with the EMR that validates H&P note timeliness and completeness before surgery. It alerts the surgical team in real time if the note is outdated or improperly modified, and provides an audit trail to clarify responsibility. This prevents last-minute scrambling and unfair blame on nurses.