Periop Healthcare Information Management

Question 1

Properly executed informed consent for surgery includes:

Answer 1

• Specific name of the intervention
• Indications for the proposed intervention
• Signature of the patient or the patient’s representative
Date and time and signature of the individual that witnessed the signing of the informed consent

Question 2

Preoperative Documentation Includes:

Answer 2

• Orders for antibiotic prophylaxis and administration of other ordered preoperative medications
• Preoperative visits by the surgeon and anesthesia care provider
• Preoperative skin preparation and hair removal if appropriate
• Skin assessment prior to and post hair removal or skin prep if applicable Performance of the Universal Protocol for Preventing
• Wrong Site, Wrong Procedure, Wrong Person Surgery™

Question 3

Documentation of the Intraoperative Patient Position

Answer 3

• Document patient position and all positioning devices such as bolsters, pillows, braces or sand bags
• Identify the persons who assisted in the positioning
• Document position and use of any specific positioning devices like immobilizing devices, including safety belt
• Document placement of arms

Question 4

Documenting Medications

Perioperative documentation includes all medications and solutions on and off the sterile field.

Answer 4

• the drug name
• the drug concentration
• route of administration
• dose administered
• time the dose was given

Question 5

Documentation of the placement of tubes, catheters, drains and packing

Answer 5

• The type of tubes inserted (eg Foley catheters, Penrose drains)
• The type of packing that is inserted
• The size and length
• The placement location on the patient

Verbal Orders should be documented in the perioperative record, authenticated with the physician’s signature and include the date and time ordered.