Question

Documentation of medication in the EHR during the perioperative phase include:

a) med on the field
b) how much med was given
c) time med was given
d) all of the above

Answer 1

Documentation of medication in the EHR during the perioperative phase includes all of the listed options: the medication used on the field, the quantity of medication given, and the time it was administered.

Step-by-step explanation:

Documentation of medication in the Electronic Health Record (EHR) during the perioperative phase should include d) all of the above: medication on the field, how much medication was given, and the time medication was administered. This information is crucial for maintaining accurate and comprehensive patient records, ensuring patient safety, and providing continuity of care. The perioperative phase is a critical period where precision in documentation is vital. During this time, the surgical team, including surgeons, nurses, and anesthesia professionals, must communicate and record key information such as the patient's identity, surgical site, procedure, and concerns specific to the patient's care. Additionally, they must confirm that essential steps such as administering prophylactic antibiotics and having all necessary imaging results are completed. These practices aim to minimize errors and improve outcomes for the patient.