Professional Conduct, Ethics, and Documentation
This domain tests judgment and the record you leave behind. Questions cover scope of practice, patient advocacy, confidentiality, informed consent, correction of the medical record, and the legal concepts that decide who is liable. The right answer is usually the one that protects the patient and produces an accurate, contemporaneous record.
Scope and professionalism
Work within your defined scope and the facility policy; when a request falls outside it, escalate through the chain of command rather than improvising. Maintain certification through the certifying body's continuing education cycle. Professional conduct includes respect for patient dignity, cultural competence, protecting the patient from unnecessary exposure, and speaking up about unsafe practice - advocacy is not insubordination.
Consent and confidentiality
Obtaining informed consent is the surgeon's responsibility; the surgical tech may verify the document is signed and witness the signature as required, but never explains risks or obtains consent. Protect privacy: no discussion in public areas, no photographs, and no social media posts even with identifying details removed.
Documentation
The intraoperative record is a legal document. Entries include personnel, procedure, position and padding devices, skin prep, time-out, implants with serial and lot numbers, specimens, medications and solutions, drains, tourniquet times, counts and their resolution, estimated blood loss, and any unusual event. Document what you did and what you observed, contemporaneously and objectively.
Correcting and reporting
Correct an error with a single line through the entry, your initials, date, and time, leaving the original legible - never erase, obliterate, or write over. Late entries are labeled as late. Incident reports are risk-management documents and are not filed in or referenced in the patient record.
Legal concepts
Negligence requires duty, breach, causation, and damages. Res ipsa loquitur ('the thing speaks for itself') applies when an injury could not occur without negligence, such as a retained sponge. Assault is threat, battery is unauthorized touching, and spoliation is destruction of records that may be needed in litigation.
Worked example
At final count, one lap sponge is missing. The correct documentation states the discrepancy, the search performed, the X-ray ordered and its result, notification of the surgeon, and the time closure proceeded. Writing 'counts correct' because the sponge was later found shows that the record was altered - a far worse problem than the original count.
Traps that cost marks
Charting in the incident report only; explaining risks to obtain consent; erasing a mistaken entry; removing the patient's identifying details but posting an image anyway.