Before admitting a patient to the operating room, which documents must the nurse ensure are present in the patient's chart?

Ensuring that both a signed consent form and a history and physical report are present in the patient's chart before admitting them to the operating room is critical for several reasons.

The signed consent form is a legal document that confirms the patient's understanding of the procedure, its risks, benefits, and alternatives. It protects the patient's autonomy and ensures that they have actively agreed to undergo the surgery or procedure. This step is essential to uphold ethical standards in healthcare and to minimize the risk of legal complications.

The history and physical report provides vital information about the patient's overall health status, previous medical conditions, medications, allergies, and other relevant data that may impact surgical care. This document is critical for the surgical team to assess the patient's readiness for surgery and to develop an appropriate plan for anesthesia and perioperative care.

By having both of these documents reviewed and in place, the nurse ensures that both legal and clinical responsibilities are met, enhancing patient safety and promoting effective communication among the healthcare team. This comprehensive approach minimizes the risk of complications during surgery and addresses informed consent, which is foundational to patient-centered care.