Module 8: Documentation 

🎯 Module Objectives 

1. List the components of the patient chart that are vital to the perioperative environment. 
2.  Describe a nurse’s key documentation components throughout the perioperative period, from preoperative, to intraoperative, to post-operative patient care. 
3. Explain the advantages and disadvantages of various methods of documentation. 
4. Describe the documentation obligations of the circulating and scrub nurses. 
5. Apply provincial licensing body’s documentation standards to perioperative charting methods. 
6. Recognize and use essential surgical terminology including common prefixes and suffixes. 

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📖 Required Reading 

The ORNAC Standards, Guidelines, and Position Statements for Perioperative Registered Nurses, 15th Ed., 2021
3-65 to 3-70

The ORNAC Standards, Guidelines, and Position Statements for Perioperative Registered Nurses, 16th Ed., 2023 
3.10 (3-70)
3.11 (3-75)

CNO (2019). Documentation, revised 2008 https://www.cno.org/globalassets/docs/prac/41001_documentation.pdf

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Introduction 

Accurate documentation is vital in the perioperative environment to reflect and record the care and interventions provided. Clear and concise documentation is required to communicate a patient’s needs, record the care provided, and give progress updates to all healthcare workers. This module covers different methods and important components of documentation, as well as surgical terminology.