What is the primary role of documentation in perioperative nursing?

The primary role of documentation in perioperative nursing is to provide continuity of care and legal protection. Accurate and thorough documentation ensures that all aspects of a patient's care are recorded, which is vital for maintaining a clear and comprehensive medical history. This enables healthcare providers to communicate effectively with one another, ensuring that the patient's care is consistent and coordinated across different stages of the perioperative process—preoperative, intraoperative, and postoperative.

Moreover, proper documentation serves as a critical legal safeguard. In the event of any disputes or complications, well-maintained records provide evidence of the care provided, assessments made, and decisions taken throughout the surgical process. This can protect healthcare professionals and institutions from potential liability and is crucial for meeting regulatory standards.

While keeping patients informed, assisting surgeons, and creating records for billing are important aspects of perioperative care, they do not encapsulate the primary purpose of documentation, which fundamentally revolves around continuity and legal protection.