This document discusses a nursing education session on perioperative documentation, medication labelling, and patient identification. The key points are: - The session aims to discuss principles of nursing documentation in perioperative settings, labelling of medicines and lines, and using surgical safety checklists for patient ID and procedure matching. - Nursing documentation provides accountability, records events and outcomes, explains clinical decisions, and enables continuing care. It must be accurate, non-judgemental, and contemporaneous. - Medication labelling must follow various legislation, policies, and guidelines to ensure patient safety in multiple clinical contexts including perioperative settings. - Incident reports show importance of documentation, medication safety, and human performance for patient

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Learning Outcomes
By the end of the session, you should be able to:
• Discuss principles, policy and practices for
• Nursing documentation in perioperative settings;
• Labelling of medicines, fluids and lines; and
• Patient ID and procedure matching using the surgical
safety checklist
• Identify how these topics affect YOU and consider
the implications for your practice as the agency
perioperative nurse; and
• Locate and access further information

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Nursing documentation in periop settings

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Nursing documentation is…
Evidence of your accountability
• Care has been provided
• Quality of care meets accepted standards ACORN PS4
A record of events and outcomes
An explanation of your clinical decisions and judgements
A communication tool between
• Healthcare practitioners
• Patient’s family and friends THE GARLING REPORT
• Auditors, researchers and investigators
Enables the provision of effective continuing care

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NMBA Code of Ethics 2008
Value Statement 7: Nurses value ethical management of information
The generation and management of information (including health care
records and other documents) are performed with professionalism and
integrity. This requires the information being recorded to be accurate,
non-judgemental and relevant to the health, care and treatment of a
person. All health documentation is a record that cannot be changed or
altered other than by the addition of further information.

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Policy and guidelines
Requirements for quality
documentation
• Document fact
• Document all relevant information
• Document contemporaneously
• Maintain the integrity of the
documentation

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Medication labelling – multiple contexts

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Medication labelling

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NSW Poisons Act 1966 &
Poisons & Therapeutic
Goods Regulation 2008
MoH PD2007_077
Handling of Medication
MoH PD2005_343
Medication Admin by EN
Local Health Districts
Medication Admin: EN
Facility Policies
SESLHD PD209 #
Medicine: Managing
Intraoperative Medications
Legislation and policy

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NSW Poisons Act 1966 &
Poisons & Therapeutic
Goods Regulation 2008
MoH PD2007_077
Handling of Medication
MoH PD2005_343
Medication Admin by EN
Local Health Districts
Medication Admin: EN
Facility Policies
SESLHD PD209 #
Medicine: Managing
Intraoperative Medications
NationalRecommendations
forUser-appliedLabelling

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Incidents up from 66,000 to 75,000 in 2 years
Incidents include:
Clinical management, Medications,
Pressure Injury, Human Performance,
Documentation and HCA Infections
Incident Data 2011-2012 from the CEC
http://www.cec.health.nsw.gov.au/clinical-incident-management#PIT

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Safe Surgery 2015