CNOR Domain 4: Communication and Documentation

Question 1

Documentation of perioperative nursing interventions should include what?

Answer 1

The time, location of care, and name and role of person performing care.

GPP: Information Management: 2.1.2.

Question 2

What modes of communication require documentation when significant medical advice is given to a patient?

Answer 2

In person, text, email, or phone.

GPP: Information Management: 2.6

Question 3

What is considered an ‘authentication’ process that must be completed after documentation in the healthcare record?

Answer 3

Digital signature or code key recognized as the legal representation of an individual’s signature.

GPP: Information Management: 2.8.1.

Question 4

What is considered best practice when a verbal order is received?

Answer 4

Read-back the order to the healthcare practitioner.

GPP: Information Management: 6.2.1.

Question 5

A surgical specimen should be labeled immediately upon receipt and should include what?

Answer 5

Patient identification (two unique identifiers), name of specimen, location of specimen site (including laterality), and the date.

GPP: Specimen Management: 6.3

Question 6

Specimen labels should not be placed on the what?

Answer 6

Container lid.

GPP: Specimen Management: 6.4

Question 7

What additional information should be documented in the patient’s healthcare record about specimens?

Answer 7

Type of pathology examination required (routine, gross, frozen section).

GPP: Specimen Management: 18.2

Question 8

What should be included in documentation of pharmacologic prophylaxis for VTE prevention?

Answer 8

Medication name, dose, time, and route.

GPP: VTE: 7.2

Question 9

What are some examples of barriers to effective communication related to the ‘flow’ of the procedure?

Answer 9

Equipment failure, missing instruments, instrument failure, blocking visualization of monitors.

GPP: Team Communication: 1.11

Question 10

What are DIDs referring to as contributing to miscommunication and human error in the OR?

Answer 10

Distractions, interruptions, and disruptions.

GPP: Team Communication: 1.11

Question 11

Name some critical phases of the surgical procedure when distractions should be minimized.

Answer 11

Briefing, time out, anesthesia induction and emergence, surgical counts, procedure-specific (cross clamp, clipping aneurysm), and specimen handling.

GPP: Team Communication: 1.11

Question 12

What two organizations established the standards for patient care documentation?

Answer 12

The American Nurses Association (ANA) and The Joint Commission (TJC).

B&K, p. 47.

Question 13

What is the standardized universal language for perioperative patient care documentation?

Answer 13

The Perioperative Nursing Data Set (PNDS).

B&K, p. 47.

Question 14

What percentage of serious medical errors are related to miscommunication?

Answer 14

80%.

Drain’s Perianesthesia, p. 279.

Question 15

What is the best process for hand-over communication?

Answer 15

A standardized process.

GPP: Team Communication: 2.1

Question 16

What two things are needed to decrease data loss when there is a hand off of patient care?

Answer 16

A verbal and a written hand off tool.

GPP: Team Communication: 2.5

Question 17

What does SBAR stand for?

Answer 17

Situation, Background, Assessment, Recommendation.

Drain’s Perianesthesia, p. 281.

Question 18

What does I PASS the BATON stand for?

Answer 18

Introduction, Patient, Assessment, Situation, Safety concerns, (the) Background, Actions, Timing, Ownership.

Drain’s Perianesthesia, p. 281.

Question 19

What does SWITCH stand for?

Answer 19

Surgical procedure, Wet, Instruments, Tissue, Counts, Have you any questions.

Drain’s Perianesthesia, p. 281.

Question 20

What does SURPASS stand for?

Answer 20

SURgical PAtient Safety System.

Drain’s Perianesthesia, p. 281.

Question 21

What percentage of information shared during hand off communication is not documented in the patients medical record?

Answer 21

20%-30%.

Drain’s Perianesthesia, p. 281.

Question 22

What documentation is necessary when positioning the patient during surgery?

Answer 22

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.

GPP: Positioning the Patient: 15.1.1.

Question 23

What information is recommended by AATB for documentation about autologous tissue recovery?

Answer 23

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.

GPP: Autologous Tissue Management: 14.2

Question 24

When using a laser during head and neck surgery, what should specifically be documented?

Answer 24

On and off times of the laser.

GPP: Laser Safety: 22.1

Question 25

What should be documented in a patient's medical record related to laser use during surgery?

Answer 25

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). ## Footnote GPP: Laser Safety: 22.1

Question 26

When must medication administration be documented?

Answer 26

After the medication is administered. ## Footnote GPP: Medication Safety: 17.1.1.

Question 27

How should you document medication when administering multiple doses of the same medication during a single procedure?

Answer 27

Documentation should include the total amount of medication administered when multiple injections of the same medication (e.g., lidocaine) are administered during a procedure. ## Footnote GPP: Medication Safety: 17.4.

Question 28

What should be documented related to preoperative hair removal?

Answer 28

Documentation should include the person performing hair removal, the hair removal method, time of removal, and area of hair removal. ## Footnote GPP: Patient Skin Antisepsis: 3.2.8.

Question 29

After the preoperative bath or shower, instruct the patient to what?

Answer 29

Not apply any alcohol-based products, skin emollients, or lotions. ## Footnote GPP: Patient Skin Antisepsis: 2.5.2.

Question 30

How is communication included in the rights of delegation?

Answer 30

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. ## Footnote Alex, p. 8.

Question 31

What are some key communication tools developed to promote patient safety during the perioperative period?

Answer 31

The surgical safety checklist, briefings, debriefings, and hand-off/handover protocols. ## Footnote Alex, p. 22.

Question 32

What is the purpose of handoff communication?

Answer 32

To provide essential, up-to-date, and specific information about the patient when care responsibility passes from one team or individual caregiver to another. ## Footnote Alex, p. 23.

Question 33

When is it safe to text patient health information or orders?

Answer 33

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). ## Footnote The Joint Commission, Standards FAQ.

Question 34

What information should be included in patient teaching about nonpharmacological pain management techniques?

Answer 34

Teaching should include nonpharmacologic methods of pain control, such as imagery, distraction, massage, music therapy, and relaxation. ## Footnote Alex, p. 281.

Question 35

What is required to ensure uninterrupted patient care when there is a breakdown in electronic health record (EHR) systems?

Answer 35

Downtime forms must be available and a policy in place for transferring information to the EHR. ## Footnote GPP: Information Management: 1.5.

Question 36

What documentation is required for a patient that was a victim of a crime and will have forensic specimens?

Answer 36

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. ## Footnote B&K, p. 122.

Question 37

What should be documented when a tourniquet is used during surgery?

Answer 37

Document tourniquet location, time, pressure, and unit identifying number. ## Footnote B&K, p. 770.

Question 38

What is the best process for communicating with a patient that is blind?

Answer 38

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. ## Footnote B&K, p. 103.

Question 39

Why is it important to place a telephone call to the patient within 48 hours after surgery?

Answer 39

Follow-up telephone calls reduce hospital readmissions by recognizing lack of patient knowledge and preventing medical problems. ## Footnote B&K, p. 205.

Question 40

What is defined as the nondisclosure of personal information that has been communicated within the nurse-patient relationship?

Answer 40

Confidentiality. ## Footnote (ANA Code of Ethics, Provision 3.1)