CONTINUING EDUCATION

Clinical Issues

1.0

KATHLEEN D. WOODS, BSN, RN

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Purpose/Goal
To educate perioperative nurses about providing safe nursing
care throughout the perioperative continuum.

Objectives
1. Discuss practices that could jeopardize safety in the perioperative area.
2. Discuss common areas of concern that relate to perioperative best practices.
3. Describe implementation of evidence-based practice in
relation to perioperative nursing care.

Ms Woods has no declared affiliation that could be perceived

as posing a potential conflict of interest in the publication of
this article.
The behavioral objectives for this program were created
by Helen Starbuck Pashley, MA, BSN, RN, CNOR, clinical
editor, with consultation from Susan Bakewell, MS, RN-BC,
director, Perioperative Education. Ms Starbuck Pashley and
Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.

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No sponsorship or commercial support was received for this
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education by the American Nurses Credentialing Centers
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AORN recognizes these activities as continuing education

for registered nurses. This recognition does not imply that
AORN or the American Nurses Credentialing Center approves
or endorses products mentioned in the activity.

http://dx.doi.org/10.1016/j.aorn.2012.09.008

658 j AORN Journal

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Vol 96 No 6

AORN, Inc, 2012

CLINICAL ISSUES

1.0

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This Month
Informed consent for repeated procedures
Key words: informed consent, sequential procedures, serial procedures, repeat procedures, power
of attorney.

Obtaining informed consent after administration of preoperative sedation

Key words: informed consent, surgical consent, preoperative sedation.

Use of medical scribes in perioperative services

Key words: medical scribes, clinical information managers, health care worker.

Informed consent for repeated procedures

QUESTION:
We often have patients who come to the OR multiple times for repeated procedures (eg, bronchial
washings, debridement of wounds or burns). Some
of these patients do not have the capacity to sign
an informed consent, and we must find the person
holding medical power of attorney each time. Does
AORN have guidelines regarding the need for
a new consent each time a patient returns to
the OR for the same procedure?
ANSWER:
AORNs Recommended practices for perioperative health care information management, states,
the patient care record must include a complete and
accurate informed patient consent for each surgical
or invasive procedure to be performed.1(p386) There
is no recommendation regarding the duration of
consent. Informed consent is most commonly given
per treatment/procedure; if the health care provider
has knowledge that the treatment course will require

several secondary or follow-up treatments, this

may be discussed and documented along with
ramifications in order for the patient or his or
her representative to accept or reject the course
prescribed.2 Health care organization policies
should specify the criteria for consent, including
the length of the proposed treatment period when
repeated procedures are performed.2 In the case
of repeated procedures or treatments, informed
consent is an ongoing process that should provide an opportunity for periodic review of the
patients understanding and confirmation of
continued consent.3
A new consent form should always be signed
if the patients condition changes or other aspects
surrounding the treatment or procedure have
changed (eg, bronchoscopy with biopsy) since
the original consent was given. The perioperative
nurses role is to facilitate a new informed consent process if the preoperative assessment has
determined a change in the patients condition or

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December 2012 Vol 96 No 6

there is a deviation in the treatment period or plan.

Generally, consents for treatment should be valid
for an individual procedure or a planned treatment
course during a specified treatment period that has
been discussed and agreed upon by the physician
and the patient or his or her representative.2
In the past, obtaining informed consent was solely
the responsibility of the physician. The Centers for
Medicare & Medicaid Services regulations now
require facilities to establish a process that ensures
that the health care team evaluates the patients or
his or her representatives level of understanding
regarding the patients health, diagnosis, and prognosis and the risks and benefits of the proposed
procedure. This ensures that the patient or the legal
representative is involved in planning care and is
able to make an informed decision. The process
also should include criteria for obtaining consent
when the patient is not competent to give it or
refuses treatment or when consent is needed for
repeated procedures.4 The perioperative nurse can
facilitate a policy review to ensure that facility
policy meets the needs of this particular patient.
It is important to understand the differences
between informed consent and obtaining signatures
documenting that informed consent has taken
place. Informed consent is more than just an
administrative or legal task performed by the perioperative nurse to witness the patients signature.
It is an opportunity to build a meaningful rapport
and trusting relationship with the patient and the
patients family members and serves as a means to
validate the patients understanding of the planned
procedure or treatment.5,6 Goals of an informed
consent process include to

The informed consent process involves the exchange of information between the patient and his
or her professional caregivers. The physician is
responsible for explaining in detail the patients
diagnosis; the nature and purpose of the planned
procedure or treatment; alternatives that may be
available, including no treatment; and the benefits and
risks of all options.8 An effective model of communication for obtaining informed consent is the teachback method, in which the provider explains the
principal message in clear and simple language and
then asks the patient to rephrase the message based on
his or her understanding.6,9 It is also the duty of the
physician to evaluate the degree to which the patient
understands the information presented, discuss any
additional questions or assumptions the patient may
have, and determine whether the patient has accepted
the risks and is agreeing to the planned procedure.
The perioperative nurses role as the patients
advocate means that the nurse is responsible for protecting the patients dignity, identifying and addressing any expressed fears, and determining the patients
ability to understand what has been discussed and
make an informed decision. The perioperative nurse
should not provide additional information or answer
questions pertaining to risks, benefits, or alternatives,3
but the nurse has a responsibility to report to the
physician any doubts or concerns regarding the
patients understanding or capacity to make decisions.10,11 Finally, the perioperative nurse may witness the patients legal signature on the consent form,
which properly documents the

n
n
n
n

improve outcomes,
increase patient safety,
protect patient autonomy,
promote meaningful decision making, and
reduce liability exposure.7

The informed consent process is an educational and

communication process that is an ethical obligation
and is required by regulatory statutes in all 50 states.8
660 j AORN Journal

n
n

n
n
n

name of the health care facility,

specific procedure to be performed with
indications listed,
name of the surgeon,
statements regarding the risks and benefits
as explained by the provider,
name and signature of the patient and witness, and
date and time of the signatures.1

This action of witnessing the signing of the surgical

consent also validates that the informed consent
process has been completed.3

CLINICAL ISSUES
KATHLEEN D. WOODS
BSN, RN
INFORMATICS NURSE SPECIALIST
AORN SYNTEGRITY TEAM

Editor's note: AORN Syntegrity is a registered

trademark of AORN, Inc, Denver, CO.
References
1. Recommended practices for perioperative health care
information management. In: Perioperative Standards
and Recommended Practices. Denver, CO: AORN, Inc;
2012:379-404.
2. Jerrold L. Informed consent and risk management. ineedce
.com. http://www.ineedce.com/courses/1968/PDF/1009
cei_jerrold_web.pdf. Accessed August 17, 2012.
3. Pryor F. Key concepts in informed consent for perioperative nurses. AORN J. 1997;65(6):1105-1110.
4. Center for Medicaid and State Operations/Survey and Certification Group. April 13, 2007. Centers for Medicare &
Medicaid Services. https://www.cms.gov/Medicare/Provide
r-Enrollment-and-Certification/SurveyCertificationGenInfo/
downloads/SCLetter07-17.pdf. Accessed August 17, 2012.

www.aornjournal.org

5. Rozovsky FA. Consent to Treatment: A Practical

Guide. 4th ed. Frederick, MD: Aspen Publishers; 2007:
8-11.
6. Kaibara PD. Eight ways to improve the informed consent
process. J Fam Pract. 2010;59(7):373-377.
7. Krames Patient Education. Improving the informed
consent process. FierceHealthcare Custom Publishing.
http://info.kramesstaywell.com/Portals/36339/docs/
Krames%20Informed%20Consent.pdf. Accessed
August 17, 2012.
8. Health and Ethics Policies of the AMA House of
Delegates (Policy H-140.989 and H-160.998). American Medical Association. http://www.ama-assn.org/adcom/polfind/Hlth-Ethics.pdf. Accessed August 17,
2012.
9. Implementing a National Voluntary Consensus for Informed Consent: A Users Guide for Healthcare Professionals. Washington, DC: National Quality Forum; 2005:
13, 15, 27.
10. Informed consent (Encyclopedia of Nursing & Allied
Health). eNotes. http://www.enotes.com/informed-conse
nt-reference/informed-consent-172090. Accessed August
17, 2012.
11. Murphy E. Informed consent. AORN J. 1988;47(5):
1294-1298.

Obtaining informed consent after administration of preoperative

sedation
QUESTION:
At our facility, the anesthesia care providers
prefer to medicate patients in the preoperative
holding area to decrease their anxiety. This
practice causes controversy if the patient
has not signed the informed consent before
receiving this medication. Can the patient
provide informed consent after sedation has
been given?
ANSWER:
State or local agencies may regulate sedation
considerations for the facilitys informed consent
policy. Health care organizations informed consent policies generally require obtaining the consent signatures before medication administration.1,2
According to AORNs Recommended practices
for perioperative health care information management, the informed consent process must be
documented, and a properly executed informed
consent should be obtained unless the circumstance is designated as an emergency situation.3

Perioperative nurses should be aware of the health

care organizations policy for obtaining signatures
for consent.
Collaboration and communication between
the perioperative team members is essential to
determine the sequence of key events in regard to
medication administration and documentation of
consent. If the policy states the consent signature
should be obtained before medications are given,
the nurse should be aware of actions to take when
the policy has not been followed. AORNs Recommended practices for perioperative health care
information management also states,
A comprehensive patient-centric record of care
reflects interactions between the patients health
care team and those individuals legally representing or providing physical, spiritual, or other
support services to the patient. Documentation
of interactions provides the groundwork for
transparency in care planning through effective
representation of the patients involvement in the
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December 2012 Vol 96 No 6

plan of care and contributions made toward the

treatment plan.3(p387)
The perioperative nurses role as a patient safety
advocate would include facilitating a discussion
with the patient, surgeon, and anesthesia care provider to determine the patients cognitive capacity
to sign consent forms after receiving a sedative
medication and then documenting the interactions
between the caregivers and the patient and the
reason and rationale for the decision.4-6 The documentation of this exchange also provides a testament that the patient has been involved in his or her
care and treatment.
KATHLEEN D. WOODS
BSN, RN
INFORMATICS NURSE SPECIALIST
AORN SYNTEGRITY TEAM

2.

3.

4.

5.

6.

VHA_Handbook_1004-01_Informed_Consent_Policy
_20090814.pdf. Accessed July 12, 2012.
Informed consent process and the elements of informed
consent. September 08, 2008. The Ohio State University
Human Research Protection Program Policies and Procedures. http://orrp.osu.edu/irb/osupolicies/documents/
InformedConsentProcessandtheElementsofInformedConse
nt.pdf. Accessed July 12, 2012.
Recommended practices for perioperative health care
information management. In: Perioperative Standards
and Recommended Practices. Denver, CO: AORN, Inc;
2012:379-404.
Short Life Working Group on Informed Consent. April
2009. NHS Tayside. http://www.nhstayside.scot.nhs.uk/
about_nhstay/commitees/archive/15_iaqsub/25062007/
407534.pdf. Accessed July 12, 2012.
Informed consent. In: University Hospitals Policy and Procedure Manual. The Ohio State University Wexner Medical
Center. http://medicalcenter.osu.edu/pdfs/informedconsent1
.pdf. Accessed July 12, 2012.
Consent policy. Version 2. July 2011. Health AuthoritydAbu Dhabi. http://www.haad.ae/haad/Portals/0/Poli
cies_Docs/Consent%20Policy20JUL.pdf. Accessed July
12, 2012.

References

Resource

1. VHA Handbook 1004.01. Informed Consent for Clinical

Treatments and Procedures. August 14, 2009. Department
of Veterans Affairs. http://www.ethics.va.gov/docs/policy/

Aveyard H. The requirement for informed consent prior

to nursing care procedures. J Adv Nurs. 2002;37(3):
243-249.

Use of medical scribes in perioperative services

QUESTION:
Is it acceptable to use medical scribes in the
perioperative area?
ANSWER:
The practice of using scribes has existed for thousands of years and ended primarily when printing
was invented in the early 15th century. Before
the invention of the printing press, scribes copied
books over and over again.1 Scribes have been
used in emergency departments to enter physicians
notes and follow up on prescriptions, laboratory
tests, specialty consultations, and records from
other hospitals since the early 1990s.2 This role
is experiencing a resurgence with the advent of
electronic health records (EHRs).1 With the implementation of EHRs, hospitals saw physicians
productivity decrease by as much as 30% while they
were learning to navigate and cope with the new
technology.3 Physicians also reported that they were
662 j AORN Journal

spending too much time on data entry or constantly looking at the computer screen and not the
patient.4,5 Some hospitals and physicians believe
that scribes are filling a necessary niche during the
transition from paper to electronic records.4
The primary function of medical scribes, or
clinical information managers as they are sometimes
called, is to create and maintain a patients medical
record under the supervision of a physician.5,6 They
are unlicensed health care workers and cannot act
independently, but they can document the dictation
or activities and interactions of the physician and
patient into the EHR. They also may assist in gathering test results and other ancillary documentation
to aid the physician in decision support; they may not
give verbal orders or enter orders into the EHR.5,7
Several companies and training programs offer
scribe services; however, there are no standardized
backgrounds, prerequisites, or training protocols
for scribes. The role is often performed by pre-med

CLINICAL ISSUES
students who have a desire to learn about patient
care and work flow patterns.3,5
Scribes are employed in a variety of ways, depending on the practice setting; the scribe may
accompany the physician and other health care
providers into the examination room and transcribe
the visit information into the EHR, listen and observe the encounter from an adjoining room to
assist the physician with documentation or gathering test data, or participate in these activities via
video and audio feeds from a virtual office. Some
physicians believe that adding another person in the
examination room may have a negative effect on
the doctor-patient relationship or that the patient
will feel uneasy.3-5 One approach is for the physician to interview and examine the patient, preserving the doctor-patient relationship and the
comfort of the patient; the scribe then joins the
visit to document the physicians summary of the
visits findings, including diagnosis; medication
changes; and additional recommendations, testing,
or appointments that may be required.3,6
Medical scribes are not currently being used in
inpatient facilities or perioperative settings. If a perioperative department decides to employ scribes to
assist with documentation, it is the responsibility of
the perioperative nurse to understand the facilitys
policy regarding the scribes role and the authentication process. AORNs Recommended practices
for perioperative health care information management states, Perioperative nursing documentation
should correspond to local, state, and national regulatory requirements.8(p384) If scribes are used,
policies should be in place to identify their
n

job description,
n orientation and training,
n competency, and
n performance evaluations.

www.aornjournal.org

The Joint Commission requires hospitals and

ambulatory surgery centers to maintain complete
and accurate records in which certain elements
are documented and properly authenticated.9
Policies should be in place to authenticate medical record scribe entries that are separate from
physician record entry authentication.7 Documentation entries made into the patient health
care record must include an authentication process
at the completion of the documentation process
or according to the organizations established
policies.8(p385)
KATHLEEN D. WOODS
BSN, RN
INFORMATICS NURSE SPECIALIST
AORN SYNTEGRITY TEAM
References
1. Conn J. Getting it in writing. Docs using scribes to ease
the transition to EHRs. Mod Healthc. 2010;40(6):30, 32.
2. Meyer H. The doctor (and his scribe) will see you now.
Hosp Health Netw. 2010;84(12):41-42. 44.
3. Huff C. Scribes: a write way and a wrong way. ACP Inte
rnist.org. http://www.acpinternist.org/archives/2012/02/
scribes.htm. Accessed July 12, 2012.
4. Meyer H. Scribes are doctors tech support. September 6,
2010. Los Angeles Times. http://articles.latimes.com/
2010/sep/06/health/la-he-medical-scribes-20100906. Accessed August 15, 2012.
5. Hagan K. Lets talk about medical scribes. ADHIonline.org.
http://www.ahdionline.org/Portals/0/downloads/LetsTalk
AboutMedicalScribes.pdf. Accessed July 12, 2012.
6. Dolan P. Scribes can ease documentation burdendfor
a price. November 8, 2011. AmMedNews.com. http://
www.ama-assn.org/amednews/2011/11/28/bica1128.htm.
Accessed July 12, 2012.
7. Use of unlicensed persons acting as scribes. The Joint
Commission. http://www.jointcommission.org/standards
_information/jcfaqdetails.aspx?StandardsFAQId345&
ProgramId40. Accessed July 12, 2011.
8. Recommended practices for perioperative health care
information management. In: Perioperative Standards and
Recommended Practices. Denver, CO: AORN, Inc; 2012:
379-404.
9. Record of care, treatment and services RC.01.02.01. In:
2011 Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission Resources;
2011.

The author of this column has no declared affiliation that could be perceived as posing a potential conflict of interest
in the publication of this article.

AORN Journal j 663

LEARNER EVALUATION

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CONTINUING EDUCATION PROGRAM

Clinical Issues

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his evaluation is used to determine the extent to

which this continuing education program met
your learning needs. The evaluation is printed
here for your convenience. To receive continuing
education credit, you must complete the Learner
Evaluation online at http://www.aorn.org/CE. Rate
the items as described below.
PURPOSE/GOAL
To educate perioperative nurses about providing safe
nursing care throughout the perioperative continuum.
OBJECTIVES
To what extent were the following objectives of this
continuing education program achieved?
1. Discuss practices that could jeopardize safety in the
perioperative area.
Low 1. 2. 3. 4. 5. High
2. Discuss common areas of concern that relate to
perioperative best practices.
Low 1. 2. 3. 4. 5. High
3. Describe implementation of evidence-based practice
in relation to perioperative nursing care.
Low 1. 2. 3. 4. 5. High
CONTENT
4. To what extent did this article increase your knowledge of the subject matter?
Low 1. 2. 3. 4. 5. High
5. To what extent were your individual objectives met?
Low 1. 2. 3. 4. 5. High

664 j AORN Journal

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6. Will you be able to use the information from this

article in your work setting? 1. Yes 2. No
7. Will you change your practice as a result of reading
this article? (If yes, answer question #7A. If no,
answer question #7B.)
7A. How will you change your practice? (Select all that
apply)
1. I will provide education to my team regarding
why change is needed.
2. I will work with management to change/
implement a policy and procedure.
3. I will plan an informational meeting with
physicians to seek their input and acceptance
of the need for change.
4. I will implement change and evaluate the
effect of the change at regular intervals until
the change is incorporated as best practice.
5. Other: _______________________________
7B. If you will not change your practice as a result of
reading this article, why? (Select all that apply)
1. The content of the article is not relevant to my
practice.
2. I do not have enough time to teach others
about the purpose of the needed change.
3. I do not have management support to make
a change.
4. Other: ________________________________
8. Our accrediting body requires that we verify
the time you needed to complete the 1.0 continuing education contact hour (60-minute)
program: _________________________________

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