Certified Surgical Technologist (CST) Practice Exam

What institutional document is completed when an adverse or unusual event takes place in the OR that may have legal consequences?

1. Incident report

2. Operative record

3. Deposition report

4. Advance directive

The correct answer is: Incident report

An incident report is the institutional document that is completed when an adverse or unusual event occurs in the operating room (OR) that could lead to legal implications. This report serves as a formal account of the incident, detailing the circumstances surrounding it, what occurred, and any individuals involved. Completing an incident report is crucial as it helps in documenting the event for legal protection and analysis, facilitating continuous quality improvement, and potentially guiding future preventive actions within the healthcare institution. The operative record is a comprehensive document that includes details about the surgical procedure performed, such as the patient's information, the procedure, and the findings. While it is an important record, it does not specifically focus on adverse events or legal consequences. A deposition report is associated with legal proceedings where a witness provides sworn testimony. It is not a document generated in response to an incident within the OR. An advance directive is a legal document that outlines a patient's preferences for medical treatment if they become unable to make decisions for themselves. This is unrelated to adverse events and does not serve to document incidents occurring in the operating room.