Perioperative Communication and Documentation Flashcards
7 cards from real CNOR practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Perioperative Communication and Documentation flashcards as text
Which component of SBAR communication represents the nurse's assessment of the patient's condition?
Answer: Assessment — the nurse's clinical judgment
The 'A' in SBAR stands for Assessment, where the nurse communicates her clinical interpretation of the situation.
An incorrect needle count is discovered after wound closure in a laparoscopic case. What is the most appropriate next step?
Answer: Notify the surgeon so an X-ray can be obtained before the patient leaves the OR
An incorrect needle count after closure requires immediate surgeon notification and an intraoperative X-ray to locate the missing needle.
Which document serves as the legal operative record and must be signed by the operating surgeon?
Answer: Operative report / dictated operative note
The operative report, dictated or written by the surgeon, is the legal document describing the procedure performed and must be completed promptly.
When documenting irrigation fluid used during a procedure, the perioperative nurse should record which of the following?
Answer: Type, volume instilled, and volume returned
Accurate fluid balance documentation requires recording the type of irrigant, the volume instilled, and the volume retrieved to track fluid absorption.
A surgeon requests a change in the surgical procedure after the timeout is complete. What action must the perioperative team take?
Answer: Conduct a new timeout to verify the change before proceeding
Any significant change in the planned procedure requires repeating the surgical timeout to ensure all team members are aligned.
What is the purpose of the preoperative checklist in perioperative documentation?
Answer: To verify completion of required safety checks before transferring the patient to the OR
The preoperative checklist ensures all required safety verifications—consent, labs, allergies, NPO status—are completed before the patient enters the OR.
Which principle guides the documentation of a critical event such as unexpected hemorrhage during surgery?
Answer: Record events in real time or as close to real time as possible with accurate timestamps
Real-time or near-real-time documentation with accurate timestamps provides the most legally defensible and clinically accurate account of critical intraoperative events.