• If hair removal was not required for the procedure and there is no documentation of hair removal, select 1: “No documented hair removal or no hair removal performed.”
• If “shaved” is documented as the method of hair removal, select “2.” However, if the surgeon documents in the operative note that the patient was “shaved and prepped in the usual fashion,” do not collect as documentation of actual hair removal.
• If more than one method is documented, select the methods that are documented. Abstractors have the opportunity to select one or more of the allowable values. No value should be recorded more than once. If a value of 1 or 7 is selected, no other selections should be recorded.
  Examples:
  • The preoperative record has documentation of hair removal by clippers. The intraoperative record has “N/A” documented for hair removal. Select only “3- Clippers” because the value of “1” cannot be combined with another value.
  • The preoperative record has documentation of a “shave prep” and the intraoperative record has “clippers” documented. Select “2-Razors” AND “3-Clippers” as both methods are documented in the medical record.
• Select 5: “Other” if the method of hair removal is not listed in the Allowable Values.
• If there is documentation that scissors are used to remove hair, select “3.”
• Examples:
  • The patient is an 80-year-old male who had surgery for a cancerous tumor in the abdomen. Hair removal was performed by using clippers in the holding area immediately prior to surgery; select 3: “Clippers.”
  • The patient shaved the night before surgery; select 6: “Patient performed their own hair removal.”

Surgical site hair removal should only be abstracted from data sources that document actual hair removal.

• Nursing notes
• Operating room record
• OR nurses record
• Preoperative checklist
• Preoperative report
• Surgical checklist