CNOR D4: Communication and Documentation Flashcards
(20 cards)
What percentage of information shared during hand off communication is not documented in the patients medical record?
20%-30%.
Drain’s Perianesthesia
What documentation is necessary when positioning the patient during surgery?
The specific actions taken to prevent patient injury (e.g., position, positioning devices, repositioning for high-risk patients or procedures at established intervals), especially any actions taken in response to findings from the preoperative assessment.
AORN Guideline Positionin the Patient
What information is recommended by AATB for documentation about autologous tissue recovery?
Patient identifiers (e.g., name, medical record number, date of birth), tissue type, date and time of recovery, and the name of the physician recovering the tissue.
AORN Guideline Autologous Tissue Management
When using a laser during head and neck surgery, what should specifically be documented?
On and off times of the laser.
AORN Guideline Laser Safety
What should be documented in a patient’s medical record related to laser use during surgery?
Documentation should include wavelength used, safety measures implemented during laser use, total energy used, total activation time, on and off time for head and neck procedures, laser device identification (e.g., serial or biomedical number), and patient protection used (e.g., type of eyewear, eye shield).
AORN Guideline Laser Safety
When must medication administration be documented?
After the medication is administered.
AORN Guideline Medication Safety
How should you document medication when administering multiple doses of the same medication during a single procedure?
Documentation should include the total amount of medication administered when multiple injections of the same medication (e.g., lidocaine) are administered during a procedure.
AORN Guideline Medication Safety
What should be documented related to preoperative hair removal?
Documentation should include the person performing hair removal, the hair removal method, time of removal, and area of hair removal.
AORN Guideline Patient Skin Antisepsis
After the preoperative bath or shower, what specific instruction should the patient receive?
Not apply any alcohol-based products, skin emollients, or lotions.
AORN Guideline Patient Skin Antisepsis
How is communication included in the rights of delegation?
Right of communication when delegating includes clear, specific, and concise description of the task, with key information relating to its objectives, rationale, limits, and expectations.
Alexander’s Care of the Patient in Surgery
What are some key communication tools developed to promote patient safety during the perioperative period?
The surgical safety checklist, briefings, debriefings, and hand-off/handover protocols.
Alexander’s Care of the Patient in Surgery
What is the purpose of handoff communication?
To provide essential, up-to-date, and specific information about the patient when care responsibility passes from one team or individual caregiver to another.
Alexander’s Care of the Patient in Surgery
When is it safe to text patient health information or orders?
When texting occurs through a Health Insurance Portability and Accountability Act (HIPAA)-compliant Secure Texting Platform (STP) and in compliance with the Conditions of Participation by the Centers for Medicare & Medicaid Services (CMS).
The Joint Commission, Standards FAQ.
What information should be included in patient teaching about nonpharmacological pain management techniques?
Teaching should include nonpharmacologic methods of pain control, such as imagery, distraction, massage, music therapy, and relaxation.
Alexander’s Care of the Patient in Surgery
What is required to ensure uninterrupted patient care when there is a breakdown in electronic health record (EHR) systems?
Downtime forms must be available and a policy in place for transferring information to the EHR.
AORN Guideline Information Management
What documentation is required for a patient that was a victim of a crime and will have forensic specimens?
Documentation should include any statements from the patient, the patient’s appearance, behavior, and odors. Photographic documentation of wounds, skin condition, and injuries (separate consent may be required) before skin antisepsis.
Berry & Kohn’s Operating Room Technique
What should be documented when a tourniquet is used during surgery?
Document tourniquet location, time, pressure, and unit identifying number.
AORN Guidline Information Management
What is the best process for communicating with a patient that is blind?
Make noise as you approach and introduce yourself, explain what is going to happen before touching them, and gently guide their hand to the OR table when transferring from the gurney.
Berry & Kohn’s Operating Room Technique
Why is it important to place a telephone call to the patient within 48 hours after surgery?
Follow-up telephone calls reduce hospital readmissions by recognizing lack of patient knowledge and preventing medical problems.
Berry & Kohn’s Operating Room Technique
What is defined as the nondisclosure of personal information that has been communicated within the nurse-patient relationship?
Confidentiality.
(ANA Code of Ethics, Provision 3.1)
