Which components should be included in perioperative nursing documentation?

• A. Evaluation of patient outcomes and nursing diagnosis
• B. Legal signature and occurrences of unusual events
• C. Nursing plan of care and patient subjective data
• D. Nursing interventions and surgical history

Answer: (B)

In perioperative nursing documentation, including a legal signature and occurrences of unusual events is essential for several reasons. The legal signature serves to validate the documentation, establishing accountability and ensuring that the information recorded is credible. This is crucial in a perioperative setting, where accurate records can influence patient care and legal outcomes.

Occurrences of unusual events must be documented to provide a clear account of any incidents that deviate from the standard care procedures. This can include anything from equipment failures to unexpected patient reactions. Documenting such events helps in maintaining quality control, facilitating investigations if needed, and improving future practices by identifying areas for better training or procedure refinement. Overall, these elements are vital for comprehensive and legally defensible documentation in perioperative nursing, supporting both patient safety and accountability in nursing practice.