CFA Operative Note Documentation 2 — Questions and Answers
Question 1: Which element of the operative note describes the patient's body position on the operating table?
- Patient position (Correct answer)
- Surgical approach
- Anesthesia type
- Incision description
Correct answer: Patient position
Patient position (e.g., supine, prone, lateral decubitus) is a required component of the operative note.
Question 2: In an operative note, 'estimated blood loss' (EBL) is most accurately calculated by:
- Visual estimation by the surgeon only
- Suction canister volume plus sponge weight minus irrigation (Correct answer)
- Anesthesia record alone
- Postoperative hemoglobin drop
Correct answer: Suction canister volume plus sponge weight minus irrigation
EBL is calculated by measuring suction volume and weighing sponges, then subtracting irrigation volume used.
Question 3: When documenting surgical counts in the operative note, the first assist should note:
- Only incorrect counts
- That counts were correct or any discrepancies and resolution (Correct answer)
- The scrub technician's name only
- Count results are not included in the operative note
Correct answer: That counts were correct or any discrepancies and resolution
The operative note must reflect whether final counts of instruments, sponges, and sharps were correct or how any discrepancies were resolved.
Question 4: The 'findings' section of an operative note refers to:
- The preoperative diagnosis
- Intraoperative observations made during the procedure (Correct answer)
- Postoperative lab results
- The anesthesia provider's assessment
Correct answer: Intraoperative observations made during the procedure
Intraoperative findings describe what was actually observed, such as tissue condition, adhesions, or unexpected anatomy.
Question 5: Which abbreviation is commonly used in operative notes to document that a specimen was sent for pathological examination?
- POC
- Spec to path (Correct answer)
- S&S
- D&C
Correct answer: Spec to path
'Spec to path' (or 'specimen sent to pathology') indicates tissue was labeled and sent for histological analysis.
Question 6: Documenting wound classification in the operative note is important because it:
- Determines anesthesia type for future procedures
- Guides postoperative infection surveillance and risk stratification (Correct answer)
- Replaces the need for a discharge summary
- Is required only for orthopedic cases
Correct answer: Guides postoperative infection surveillance and risk stratification
Wound classification (clean, clean-contaminated, contaminated, dirty) predicts infection risk and guides postoperative monitoring and antibiotic decisions.
Question 7: When a first assist closes the fascia, the operative note should document:
- The patient's pain level
- Suture material, size, and technique used for fascial closure (Correct answer)
- The name of the circulating nurse
- Room temperature during closure
Correct answer: Suture material, size, and technique used for fascial closure
The type of suture (e.g., #1 PDS running), size, and closure technique are required for accurate documentation of the fascial layer closure.
CFA Operative Note Documentation 2
Which element of the operative note describes the patient's body position on the operating table?