Final answer:
The operative or high-risk procedure report must include names of the practitioners involved in the procedure, detailed procedure description, findings, estimated blood loss, specimens removed, and postoperative diagnosis. Confirmation of patient identity, procedure, and site, as well as a review of team members' roles, equipment, and critical events, is essential for patient safety.
Step-by-step explanation:
An operative or other high-risk procedure report is required to contain the following essential elements: the name(s) of the Licensed Independent Practitioner(s) (LIPs) who performed the procedure and any assistant(s), the name and description of the procedure performed, findings of the procedure, any estimated blood loss, any specimen(s) removed, and the postoperative diagnosis. This comprehensive report serves as a critical document, providing a record of what took place during the procedure for future reference and for the continuity of patient care. In addition, specific items are reviewed aloud with the medical team to ensure patient safety and the successful outcome of the procedure. These items include needle, sponge, and instrument counts, proper labeling of specimen (if any), and a review of any equipment issues. Also, the introduction of all team members by name and role, confirmation of the patient's identity, surgical site, and procedure, anticipated critical events, sterility confirmation, and equipment availability are addressed to ensure a thorough and accurate report.
A time out is performed before skin incision where the entire team, including nurses, surgeons, anesthesia professionals, and others participating in the care of the patient, orally confirm essential details. Prophylactic antibiotics administration timing or their indication, as well as the availability of essential imaging results displayed in the operating room, are also confirmed for inclusion in the report.