Technical Reading: Perioperative Documents & Medical Terminology

Why Technical Reading Matters in the OR

As a surgical technologist, you will read documents every single day before, during, and after a procedure. A misread consent form can mean the wrong site is prepped. A misunderstood SDS entry can mean a teammate is exposed to a hazardous chemical without the right protection. A missed allergy on a preference card can place a patient in danger. Accurate, deliberate reading is a patient-safety skill—not a clerical one.

This lesson builds two connected abilities: decoding medical terminology through prefix-root-suffix analysis, and extracting specific, actionable information from the perioperative documents you will handle as a scrub tech.

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Medical Terminology: The Building-Block System

Medical language follows a consistent structure. Most terms are assembled from three parts:

• Prefix – comes before the root; modifies meaning (e.g., brady- = slow, peri- = around)
• Word root / combining form – the core meaning, often Greek or Latin (e.g., cardi/o = heart, lapar/o = abdominal wall)
• Suffix – comes after the root; often indicates a procedure, condition, or process (e.g., -ectomy = surgical removal, -scopy = visual examination, -stasis = stopping or controlling)

Strategy: break before you read. When you encounter an unfamiliar term, split it into its components, define each part, then reassemble.

Example: laparoscopy → lapar/o (abdominal wall) + -scopy (visual examination) = visual examination of the abdominal cavity.

Example: hemostasis → hemo- (blood) + -stasis (stopping) = the stopping or controlling of bleeding.

Example: cholecystectomy → chol/e (bile) + cyst (bladder/sac) + -ectomy (surgical removal) = surgical removal of the gallbladder.

Build a personal reference log as you encounter terms. Write the breakdown, a plain-language definition, and a surgical-context sentence. This log becomes a study tool for your CST examination.

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Perioperative Documents You Must Read Accurately

Surgical Consent Forms

The informed consent document confirms that the patient or legal guardian has agreed to a specific procedure after receiving an explanation of risks, benefits, and alternatives. As the scrub tech, you use the consent form during case preparation to verify:

• Procedure name – does it match the surgeon's preference card and the OR schedule?
• Laterality – is the correct side (left/right/bilateral) clearly documented? This is a Joint Commission Universal Protocol requirement.
• Surgeon's attestation – has the operating surgeon signed?
• Allergies and implant history – some consent forms include allergy notation; cross-check with the chart.

Never assume. If the consent form is absent, incomplete, or does not match the scheduled procedure, stop and notify the circulating nurse and surgeon before the patient enters the room.

Preference Cards and Instrument Set Cards

Preference cards (also called surgeon preference cards or pick lists) document a specific surgeon's equipment choices, suture preferences, glove size, positioning requirements, and special supplies for a given procedure. Instrument set cards list every instrument in a tray by name and count.

Read both before every case. Use them to build the sterile field correctly, anticipate the surgeon's needs, and complete the opening count accurately. Discrepancies between the set card count and the actual tray must be reported immediately.

Operative Reports

The operative report is the surgeon's written record of what occurred during a procedure—incision site, findings, techniques used, implants placed, blood loss, and closure method. As a student, you will read operative reports to build vocabulary and understand procedural sequences. In practice, you may reference them when preparing for similar future cases.

When reading an operative report, identify: the pre- and post-operative diagnosis, the procedure performed, any specimens sent to pathology, and implants or foreign material left in the patient.

Safety Data Sheets (SDS)

Formerly called Material Safety Data Sheets (MSDS), SDS documents are standardized under the OSHA Hazard Communication Standard (HazCom). Every hazardous chemical in the workplace must have an SDS available to employees. OR chemicals such as glutaraldehyde (used for high-level disinfection of scopes), isopropyl alcohol, and iodophor solutions each carry specific hazards.

A standard SDS contains 16 sections. For your daily OR safety, focus on:

• Section 2 – Hazard identification (what danger does it pose?)
• Section 4 – First aid measures (what to do if exposure occurs)
• Section 8 – Exposure controls and PPE (what protection is required?)
• Section 13 – Disposal considerations

Glutaraldehyde, for example, is a respiratory and skin sensitizer requiring a properly fitted respirator, chemical-resistant gloves, and eye protection. Know the SDS before you open the container.

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Safety First: Document Errors Have Consequences

• Wrong-site surgery is a never event. Laterality errors on consent and site-marking failures are leading causes. Read the consent; confirm the mark.
• Retained surgical items are linked to incorrect count documentation. Read instrument set cards; count every item.
• Chemical exposure injuries are preventable. Read the SDS; wear the required PPE before handling any OR chemical.
• Scope of practice reminder: If you find a discrepancy in any document, you do not proceed independently—you communicate it immediately to the circulating nurse or surgeon.