The circulating nurse in the OR notices a small laceration on the patient's hip while positioning pre-op, but this was missed and not reported during the pre-op assessment. Of the following, which is the appropriate action for the nurse to take?

Document the presence of a preexisting skin laceration in the peri-op note now.


•Document the presence of a preexisting skin laceration in the peri-op note now.

•Preop assessments should always include any skin tears or lacerations, bruises, rashes, and pressure ulcers, so they can be documented and will not be misattributed to a surgical injury or complication.

•A nurse may never alter documentation after the fact or alter the documentation of another nurse (this is illegal). So if something is missed, a note should be made in the peri-op documentation to detail the preexisting injury.

Incorrect options:

•Do not add the laceration to the preop nurse's documentation. This is illegal.

•Do not document the laceration along with the surgical sites in the peri-op note, because this would cause confusion and make it appear that the laceration was another surgical site or surgical injury.

•The nurse should not pass it off to the receiving PACU nurse to document it.

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