CNOR 2 D4: Communication and Documentation Flashcards
(20 cards)
Documentation of perioperative nursing interventions should include what?
The time, location of care, and name and role of person performing care.
AORN Guideline Information Management
What modes of communication require documentation when significant medical advice is given to a patient?
In person, text, email, or phone.
AORN Guideline Information Management
What is considered an ‘authentication’ process that must be completed after documentation in the healthcare record?
Digital signature or code key recognized as the legal representation of an individual’s signature.
AORN Guideline Information Management
What is considered best practice when a verbal order is received?
Read-back the order to the healthcare practitioner.
AORN Guideline Information Management
A surgical specimen should be labeled immediately upon receipt and should include what?
Patient identification (two unique identifiers), name of specimen, location of specimen site (including laterality), and the date.
AORN Guideline Specimen Management
Specimen labels should not be placed on the what?
Container lid.
AORN Guideline Specimen Management
What additional information should be documented in the patient’s healthcare record about specimens?
Type of pathology examination required (routine, gross, frozen section).
AORN Guideline Specimen Management
What should be included in documentation of pharmacologic prophylaxis for VTE prevention?
Medication name, dose, time, and route.
AORN Guidleine Venous Thromboembolism
What are some examples of barriers to effective communication related to the ‘flow’ of the procedure?
Equipment failure, missing instruments, instrument failure, blocking visualization of monitors.
AORN Guideline Team Communication
What are DIDs referring to as contributing to miscommunication and human error in the OR?
Distractions, interruptions, and disruptions.
AORN Guideline Team Communication
Name some critical phases of the surgical procedure when distractions should be minimized.
Briefing, time out, anesthesia induction and emergence, surgical counts, procedure-specific (cross clamp, clipping aneurysm), and specimen handling.
AORN Guideline Team Communication
What two organizations established the standards for patient care documentation?
The American Nurses Association (ANA) and The Joint Commission (TJC).
Berry & Kohn’s Operating Room Technique
What is the standardized universal language for perioperative patient care documentation?
The Perioperative Nursing Data Set (PNDS).
Berry & Kohn’s Operating Room Technique
What percentage of serious medical errors are related to miscommunication?
80%.
Drain’s Perianesthesia
What is the best process for hand-over communication?
A standardized process.
AORN Guideline Team Communication
What two things are needed to decrease data loss when there is a hand off of patient care?
A verbal and a written hand off tool.
AORN Guideline Team Communication
What does SBAR stand for?
Situation, Background, Assessment, Recommendation.
Drain’s Perianesthesia
What does I PASS the BATON stand for?
Introduction, Patient, Assessment, Situation, Safety concerns, (the) Background, Actions, Timing, Ownership.
Drain’s Perianesthesia
What does SWITCH stand for?
Surgical procedure, Wet, Instruments, Tissue, Counts, Have you any questions.
Drain’s Perianesthesia
What does SURPASS stand for?
SURgical PAtient Safety System.
Drain’s Perianesthesia
