Documentation Standards
📽️ AORN CINE-MED VIDEO
Navigate to the AORN Cine-Med website and make sure that you are logged in before clicking on the link below.
- Begin this module by logging in to watch the AORN Cine-Med Video on Perioperative Patient Information Management
- Download the Study Guide included to follow along.
- (Thread to follow in Cine-Med – Management concepts Perioperative Patient Information Management)
- Runtime – 19 minutes
Perioperative nurses must follow their provincial licensing body’s documentation standards when providing care. In Ontario, this falls under the College of Nurses of Ontario (CNO).
Please click on the following link to review the CNO practice standard on documentation 41001_documentation (cno.org).
Nurses are required to follow their provincial licensing body’s standards when it comes to documentation. In Ontario, the CNO has three key standard statements and indicators:
- Communication
- Accountability
- Security
How do perioperative nurses uphold these standard statements and indicators?
(CNO, 2019)
In addition to the CNOs (College of Nurses of Ontario) practice standards, perioperative nurses follow the ORNAC guidelines which provide specific guidance related to documentation in the operating room.
Nurses must also follow the documentation policies and procedures at their individual facilities.
Documentation through the Perioperative Phases of Care
During each of the perioperative phases, documentation must be completed by the OR team. Handover of information occurs at various points of care, and all team members must receive the appropriate communication and documentation to provide appropriate patient care. You will learn more detailed information in course two; however, the next pages will provide an overview.