AORN Documentation 3 — Questions and Answers
Question 1: How should the perioperative nurse document a patient's allergy to latex that was discovered in the preoperative assessment?
- In the allergy section of the intraoperative record and communicated in the hand-off report (Correct answer)
- Only verbally to the scrub technician
- On a sticky note attached to the chart
- In the postoperative care unit record only
Correct answer: In the allergy section of the intraoperative record and communicated in the hand-off report
Latex allergy must be prominently recorded in the allergy section of the intraoperative record and verbally communicated during every hand-off to prevent exposure.
Question 2: According to AORN, which component is REQUIRED in the documentation of a surgical time-out?
- The anesthesia start time
- Verification of patient identity, procedure, site, laterality, positioning, and implants (Correct answer)
- The surgical technologist's certification number
- The OR room temperature at time of incision
Correct answer: Verification of patient identity, procedure, site, laterality, positioning, and implants
AORN and The Joint Commission Universal Protocol require the time-out to verify patient identity, correct procedure, correct site/laterality, positioning, and anticipated implants.
Question 3: A specimen is sent to pathology without a label. What is the perioperative nurse's documentation responsibility?
- Rely on the pathology department to identify the specimen
- Document the error in the incident reporting system and notify the surgeon (Correct answer)
- Ask the scrub technician to add a label and continue without documentation
- Record the specimen as sent and make no additional entry
Correct answer: Document the error in the incident reporting system and notify the surgeon
A specimen labeling error must be entered in the incident reporting system and the surgeon notified to facilitate corrective action and prevent misdiagnosis.
Question 4: When documenting positioning devices used during a surgical procedure, the perioperative nurse should record:
- Only the type of OR table used
- All positioning devices, their locations, and the name of the person who applied them (Correct answer)
- A general statement that 'standard positioning was used'
- The surgeon's written positioning order only
Correct answer: All positioning devices, their locations, and the name of the person who applied them
Specific documentation of all positioning aids, their placement, and who applied them supports accountability and helps investigate any postoperative positioning injuries.
Question 5: Which is the MOST appropriate way to correct a documentation error in a paper-based intraoperative record?
- Use correction fluid to cover the error and write the correct information
- Completely black out the error so it is unreadable
- Draw a single line through the error, write the correction, and add date, time, and initials (Correct answer)
- Discard the page and restart on a new form
Correct answer: Draw a single line through the error, write the correction, and add date, time, and initials
A single line through the error with the correction, date, time, and initials preserves the original entry and maintains record integrity.
Question 6: What is the perioperative nurse's documentation obligation when a patient refuses a planned surgical site preparation (e.g., shave prep)?
- Perform the prep anyway and document 'completed as ordered'
- Document the refusal, the education provided, and the surgeon notification (Correct answer)
- Skip the prep without any documentation
- Document that the surgeon waived the prep
Correct answer: Document the refusal, the education provided, and the surgeon notification
Patient refusal must be documented along with the education provided regarding risks, and the surgeon must be notified so an informed decision can be made.
Question 7: How should the perioperative nurse document a medication administered by the surgeon directly from the sterile field?
- The surgeon documents it independently; the nurse has no obligation
- The nurse documents the medication name, dose, route, time, and the name of the administering surgeon (Correct answer)
- Only document if the medication is a controlled substance
- Document as 'surgeon administered' without further detail
Correct answer: The nurse documents the medication name, dose, route, time, and the name of the administering surgeon
All medications administered in the OR, regardless of who gives them, must be documented with full details including drug, dose, route, time, and the administering provider.
AORN Documentation 3
How should the perioperative nurse document a patient's allergy to latex that was discovered in the preoperative assessment?