AORN Documentation 2 — Questions and Answers
Question 1: When documenting a surgical count discrepancy that is resolved before wound closure, what must the perioperative nurse record?
- Only the final correct count
- The discrepancy, corrective actions taken, and final reconciled count (Correct answer)
- The discrepancy and surgeon notification only
- A verbal report to the charge nurse with no written entry
Correct answer: The discrepancy, corrective actions taken, and final reconciled count
AORN guidelines require documentation of the initial discrepancy, all corrective actions taken, and the final reconciled count to ensure a complete record.
Question 2: Which element is MOST critical to include when documenting the application of a pneumatic tourniquet?
- The brand name of the tourniquet
- Inflation pressure, cuff location, and inflation/deflation times (Correct answer)
- The surgeon's tourniquet preference
- The patient's blood pressure at tourniquet application
Correct answer: Inflation pressure, cuff location, and inflation/deflation times
AORN standards require documentation of inflation pressure, cuff location, and the times of inflation and deflation to monitor for ischemic injury.
Question 3: A patient arrives to the OR without a signed informed consent. What is the perioperative nurse's FIRST documentation action?
- Proceed and document that consent was implied
- Document the missing consent and notify the surgeon and charge nurse before proceeding (Correct answer)
- Have the circulator sign as a witness and proceed
- Document that the patient verbally agreed in the holding area
Correct answer: Document the missing consent and notify the surgeon and charge nurse before proceeding
The nurse must document the absence of consent and escalate to the surgeon and charge nurse; surgery should not proceed until proper consent is obtained.
Question 4: When documenting implant information in the intraoperative record, which data element is required by AORN and The Joint Commission?
- The cost of the implant
- The surgeon's implant preference card number
- The implant lot number and manufacturer name (Correct answer)
- The scrub technician who opened the implant
Correct answer: The implant lot number and manufacturer name
Lot number and manufacturer are required for implant traceability so patients can be notified in the event of a recall.
Question 5: Which statement about late entries in the perioperative nursing record is CORRECT?
- Late entries are not permitted under any circumstances
- A late entry should be labeled as such with the current date, time, and reason for the delay (Correct answer)
- Late entries should be backdated to the time the event occurred
- Late entries require co-signature from the operating surgeon
Correct answer: A late entry should be labeled as such with the current date, time, and reason for the delay
A late entry must be clearly identified with the actual date and time of documentation and the reason for the delay to maintain record integrity.
Question 6: When documenting blood loss during a procedure, which source should the perioperative nurse use as the primary reference for the estimated amount?
- The scrub technician's visual estimate
- The anesthesia provider's running blood loss total
- Suction canister volume plus surgical sponge weights (Correct answer)
- The surgeon's verbal estimate at wound closure
Correct answer: Suction canister volume plus surgical sponge weights
Accurate estimated blood loss (EBL) is calculated by measuring suction canister volumes and weighing surgical sponges to quantify blood absorbed.
Question 7: Which action best demonstrates compliance with AORN standards for documentation of a fire safety drill event on the surgical suite?
- Verbal briefing to all staff with no written record
- Documentation in each staff member's personnel file only
- An incident report plus an entry in the quality improvement log with corrective actions (Correct answer)
- A note written on the department whiteboard
Correct answer: An incident report plus an entry in the quality improvement log with corrective actions
AORN requires formal documentation of safety events and drills, including findings and corrective actions, within quality improvement systems.
AORN Documentation 2
When documenting a surgical count discrepancy that is resolved before wound closure, what must the perioperative nurse record?