Post-Prosthesis Insertion Documentation Checklist

Essential documentation after joint prosthesis implantation (hip, knee, shoulder, etc.):

Mandatory Elements

• Patient identifiers: Name, DOB, MRN.
• Date, time, location (OR #).
• Procedure: Laterality, implant type (cemented/uncemented), component IDs (catalog/lot numbers), bearing surface.
• Surgeon name, signature, assistant(s).
• Anesthesia type, duration, any complications.
• Intraoperative findings: Bone quality, ligament balance, range of motion achieved.
• Blood loss, transfusions, drains.
• Antibiotic prophylaxis (agent, timing, redosing).
• VTE prophylaxis (mechanical/pharmacologic).
• Post-op orders: Weight-bearing status, precautions (hip: no flexion >90°, no internal rotation), PT protocol, pain management, wound care, follow-up schedule.
• Contact for post-discharge concerns.

Best Practice

• Use structured operative note template.
• Enter implant data into registry (AJRR, NJR).
• Provide patient with implant card.