CNOR Domain 4: Communication and Documentation Flashcards
What certification is required for electronic patient healthcare records determined by CMS?
Health Information Technology (HIT) certification.
GPP: Information Management: 1.1.1.
Documentation of perioperative nursing interventions should include the time, location of care, and ___________
name and role of person performing care.
GPP: Information Management: 2.1.2.
What modes of communication require documentation when significant medical advice is given to a patient?
In person, text, email, or phone.
GPP: Information Management: 2.6
What is considered an ‘authentication’ process that must be completed after documentation in the healthcare record?
Digital signature or code key recognized as the legal representation of an individual’s signature.
GPP: Information Management: 2.8.1.
What must the perioperative nurse do in relation to the consent before an operative or other invasive procedure?
Verify informed consent.
GPP: Information Management: 5.1
The length of time an informed consent may be used is determined by whom?
The healthcare organization policy.
GPP: Information Management: 5.3.
What is considered best practice when a verbal order is received?
Read-back the order to the healthcare practitioner.
GPP: Information Management: 6.2.1.
A surgical specimen should be labeled immediately upon receipt and should include___________
Patient identification (two unique identifiers), name of specimen, location of specimen site (including laterality), and the date.
GPP: Specimen Management: 6.3
Specimen labels should not be placed on the__________
container lid.
GPP: Specimen Management: 6.4
What additional information should be documented in the patient’s healthcare record about specimens, besides the identification of the specimen and date and time of collection?
Type of pathology examination required (routine, gross, frozen section).
GPP: Specimen Management: 18.2
What should be included in documentation of pharmacologic prophylaxis for VTE prevention?
Medication name, dose, time, and route.
GPP: VTE: 7.2
What are some examples of barriers to effective communication related to the ‘flow’ of the procedure?
Equipment failure, missing instruments, instrument failure, blocking visualization of monitors.
GPP: Team Communication: 1.11
What are DIDs referring to as contributing to miscommunication and human error in the OR that may contribute to adverse events?
Distractions, interruptions, and disruptions.
GPP: Team Communication: 1.11
Name some critical phases of the surgical procedure when distractions should be minimized?
Briefing, time out, anesthesia induction and emergence, surgical counts, procedure-specific (cross clamp, clipping aneurysm), and specimen handling.
GPP: Team Communication: 1.11
What two organizations established the standards for patient care documentation?
The American Nurses Association (ANA) and The Joint Commission (TJC).
B&K, p. 47.
What is the standardized universal language for perioperative patient care documentation?
The Perioperative Nursing Data Set (PNDS).
B&K, p. 47.
What percentage of serious medical errors are related to miscommunication?
80%.
Drain’s Perianesthesia, p. 279.
What is the best process for hand-over communication?
A standardized process.
GPP: Team Communication: 2.1
What two things are needed to decrease data loss when there is a hand off of patient care?
A verbal and a written hand off tool.
GPP: Team Communication: 2.5
What does SBAR stand for?
Situation, Background, Assessment, Recommendation.
Drain’s Perianesthesia, p. 281.
What does I PASS the BATON stand for?
Introduction, Patient, Assessment, Situation, Safety concerns, (the) Background, Actions, Timing, Ownership.
Drain’s Perianesthesia, p. 281.
What does SWITCH stand for?
Surgical procedure, Wet, Instruments, Tissue, Counts, Have you any questions.
Drain’s Perianesthesia, p. 281.
What does SURPASS stand for?
SURgical PAtient Safety System.
Drain’s Perianesthesia, p. 281.
What percentage of information shared during hand off communication is not documented in the patient’s medical record?
20%-30%.
Drain’s Perianesthesia, p. 281.
What documentation is necessary when positioning the patient during surgery?
The specific actions taken to prevent patient injury (e.g., position, positioning devices, repositioning for high-risk patients or procedures at established intervals), especially any actions taken in response to findings from the preoperative assessment.
GPP: Positioning the Patient: 15.1.1.
What information is recommended by AATB for documentation about autologous tissue recovery?
Patient identifiers (e.g., name, medical record number, date of birth), tissue type, date and time of recovery, and the name of the physician recovering the tissue.
GPP: Autologous Tissue Management: 14.2
When using a laser during head and neck surgery, what should specifically be documented?
On and off times of the laser.
GPP: Laser Safety: 22.1
What should be documented in a patient’s medical record related to laser use during surgery?
Documentation should include wavelength used, safety measures implemented during laser use, total energy used, total activation time, on and off time for head and neck procedures, laser device identification (e.g., serial or biomedical number), and patient protection used (e.g., type of eyewear, eye shield).
GPP: Laser Safety: 22.1
When must medication administration be documented?
After the medication is administered.
GPP: Medication Safety: 17.1.1.
How should you document medication when administering multiple doses of the same medication during a single procedure?
Documentation should include the total amount of medication administered when multiple injections of the same medication (e.g., lidocaine) are administered during a procedure.
GPP: Medication Safety: 17.4.
What should be documented related to preoperative hair removal?
Documentation should include the person performing hair removal, the hair removal method, time of removal, and area of hair removal.
GPP: Patient Skin Antisepsis: 3.2.8.
After the preoperative bath or shower, instruct the patient to_________
Not apply any alcohol-based products, skin emollients, or lotions.
GPP: Patient Skin Antisepsis: 2.5.2.
How is communication included in the rights of delegation?
Right of communication when delegating includes clear, specific, and concise description of the task, with key information relating to its objectives, rationale, limits, and expectations.
Alex, p. 8.
What are some key communication tools developed to promote patient safety during the perioperative period?
The surgical safety checklist, briefings, debriefings, and hand-off/handover protocols.
Alex, p. 22.
What is the purpose of handoff communication?
To provide essential, up-to-date, and specific information about the patient when care responsibility passes from one team or individual caregiver to another.
Alex, p. 23.
When is it safe to text patient health information or orders?
When texting occurs through a Health Insurance Portability and Accountability Act (HIPAA)-compliant Secure Texting Platform (STP) and in compliance with the Conditions of Participation by the Centers for Medicare & Medicaid Services (CMS).
The Joint Commission, Standards FAQ.
What information should be documented after administering pain medication to a patient?
Document medications administered, dose, route, time, and effectiveness of pain relief.
Alex, p. 259.
If an incorrect count occurs, what information must be documented in the patient’s record?
Documentation must include all measures taken to recover the missing item, description and location of the item if known, patient notification and consultation, and the plan for follow-up care.
Alex, p. 27.
What information should be included in patient teaching about nonpharmacological pain management techniques?
Teaching should include nonpharmacologic methods of pain control, such as imagery, distraction, massage, music therapy, and relaxation.
Alex, p. 281.
What is required to ensure uninterrupted patient care when there is a breakdown in electronic health record (EHR) systems?
Downtime forms must be available and a policy in place for transferring information to the EHR.
GPP: Information Management: 1.5.
What documentation is required for a patient that was a victim of a crime and will have forensic specimens?
Documentation should include any statements from the patient, the patient’s appearance, behavior, and odors. Photographic documentation of wounds, skin condition, and injuries (separate consent may be required) before skin antisepsis.
B&K, p. 122.
What should be documented when a tourniquet is used during surgery?
Document tourniquet location, time, pressure, and unit identifying number.
B&K, p. 770.
What is the best process for communicating with a patient that is blind?
Make noise as you approach and introduce yourself, explain what is going to happen before touching them, and gently guide their hand to the OR table when transferring from the gurney.
B&K, p. 103.
Why is it important to place a telephone call to the patient within 48 hours after surgery?
Follow-up telephone calls reduce hospital readmissions by recognizing lack of patient knowledge and preventing medical problems.
B&K, p. 205.
