Communication and Documentation
Structured communication
Perioperative communication is standardized because ambiguity harms patients. The surgical time-out occurs before incision with the entire team present and engaged, verifying patient identity, procedure, site and side, consent, allergies, implants or special equipment, antibiotic administration, and relevant imaging. Handoffs use a structured format such as SBAR (situation, background, assessment, recommendation) and allow for questions and read-back. Closed-loop communication - the receiver repeats back the order - is expected when verbal orders must be given, which should be rare and always authenticated per policy.
Documentation standards
The record must be objective, accurate, timely, complete, and legible. Entries reflect what was observed and done, with times. Late entries are labeled as late and never backdated. Errors are corrected with a single line through the entry, initials, date, and time - no erasures, no correction fluid, no overwriting. The RN documents only their own care, never another clinician's. Incident or occurrence reports are quality-improvement documents and are not filed in the medical record; the facts of the event and the patient's status belong in the record.
Traps
The most common trap is the neat-sounding but false statement that an incident report should be placed on the chart. Another is believing that a verbal order can be accepted and acted upon without read-back and authentication. Consent documentation is also a favorite: the nurse witnesses the signature and the patient's understanding, but does not explain the procedure or its risks.
Rule of thumb
If it was not documented, it was not done - and if it was not read back, it was not communicated.