CNOR Perioperative Communication and Documentation 5 — Questions and Answers
Question 1: Which of the following best describes the purpose of a surgical safety checklist as recommended by the WHO?
- To replace the need for a surgical timeout
- To serve as a billing and coding tool
- To standardize communication and reduce preventable surgical complications across the three perioperative phases (Correct answer)
- To document anesthesia technique only
Correct answer: To standardize communication and reduce preventable surgical complications across the three perioperative phases
The WHO Surgical Safety Checklist is designed to improve teamwork and communication across the Sign In, Time Out, and Sign Out phases to reduce preventable harm.
Question 2: Which of the following is an example of an 'error of omission' in perioperative documentation?
- Recording the wrong drug name
- Failing to document a known allergy discovered during preoperative assessment (Correct answer)
- Signing another nurse's entry
- Using an unapproved abbreviation
Correct answer: Failing to document a known allergy discovered during preoperative assessment
An error of omission occurs when relevant information—such as a newly identified allergy—is discovered but not recorded, leaving a dangerous gap in the medical record.
Question 3: A perioperative nurse documents 'patient tolerated procedure well' without supporting objective data. This type of entry is considered:
- Legally sufficient because it is brief and professional
- Subjective and insufficient without objective assessment findings to support it (Correct answer)
- Ideal because it avoids overly detailed notes
- Standard nursing language acceptable in all facilities
Correct answer: Subjective and insufficient without objective assessment findings to support it
Documentation must include objective data such as vital signs, estimated blood loss, and patient responses rather than vague subjective statements.
Question 4: Which situation requires the perioperative nurse to complete an incident report (occurrence report) in addition to the medical record?
- A routine instrument count that is correct
- A patient fall during transfer from the OR table to the stretcher (Correct answer)
- A surgeon who arrives on time for the case
- A correctly labeled specimen sent to pathology
Correct answer: A patient fall during transfer from the OR table to the stretcher
A patient fall is an adverse event requiring both an incident/occurrence report for risk management purposes and accurate documentation in the medical record.
Question 5: During the postoperative Sign Out phase of the surgical checklist, which of the following is confirmed?
- Patient identity only
- Instrument, sponge, and needle counts; specimen labeling; equipment concerns; and key recovery concerns (Correct answer)
- Anesthesia type to be used
- Surgeon's operative technique preferences
Correct answer: Instrument, sponge, and needle counts; specimen labeling; equipment concerns; and key recovery concerns
The Sign Out phase of the WHO checklist confirms count correctness, specimen labeling, equipment problems to report, and key concerns for recovery.
Question 6: What is the purpose of documenting tourniquet application time and pressure in the intraoperative record?
- To fulfill billing requirements for tourniquet use
- To monitor for potential ischemic injury by tracking duration and inflation pressure (Correct answer)
- To document the scrub technician's technique
- To record the brand of tourniquet used for equipment tracking
Correct answer: To monitor for potential ischemic injury by tracking duration and inflation pressure
Tourniquet time and pressure must be documented to monitor for limb ischemia risk; prolonged inflation or excessive pressure can cause nerve or tissue damage.
Question 7: A perioperative nurse is asked to co-sign a documentation entry made by a nursing student. What does co-signing legally imply?
- The nurse reviewed the entry and was present or supervised the care described (Correct answer)
- The nurse is taking financial responsibility for the student's actions
- The nurse is confirming the student's identity only
- The nurse is acknowledging the entry exists but has no responsibility for it
Correct answer: The nurse reviewed the entry and was present or supervised the care described
Co-signing a student's entry signifies that the supervising nurse reviewed the documentation and either performed or directly supervised the care described.
CNOR Perioperative Communication and Documentation 5
Which of the following best describes the purpose of a surgical safety checklist as recommended by the WHO?