CNOR Operating Room Nursing

Category - Accountability

Which of the following describes appropriate documentation of patient care during the perioperative setting?
  1. It should describe the patient’s nursing diagnoses and outcomes.
  2. It should be on a preprinted form that is easy to fill in.
  3. It should be read between the nurses during report at the change of shift.
  4. Both A and B
Explanation
Answer: A - Documentation of patient care should describe the patient’s nursing diagnoses and outcomes. Although some forms are preprinted, different locations will have different methods of documentation. The information should be easy to complete, which will save the nurse some time. Nurses do not necessarily need to read over all documentation during shift report, unless the material is pertinent to the report.
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