CFA Operative Note Documentation 2

Question 1

Which element of the operative note describes the patient's body position on the operating table?

Accepted Answer

Patient position

Answer

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:

Accepted Answer

Suction canister volume plus sponge weight minus irrigation

Answer

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:

Accepted Answer

That counts were correct or any discrepancies and resolution

Answer

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:

Accepted Answer

Intraoperative observations made during the procedure

Answer

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?

Accepted Answer

Spec to path

Answer

'Spec to path' (or 'specimen sent to pathology') indicates tissue was labeled and sent for histological analysis.

CFA Practice Test