Transcript Slide 1

MISH MASH
Entering and Exiting the Operating Room
Compliance Statements
Completing the Anesthetic Record
Remote View
Progress Notes
Admission Scenario (Current)
1. SDA-MD Assessment
2. SDCU-MD Assessment
3. Anesthesia Consultation
18/07/2015
Admission Scenario (Current)
1. SDA-MD Assessment
2. SDCU-MD Assessment
3. Anesthesia Consultation
18/07/2015
Admission Scenario
1. SDA-MD Assessment
2. SDCU-MD Assessment
3. Anesthesia Consultation
Current
Practice and Future
Admission Scenario (Current)
1. SDA- NO MD Assessment
2. SDCU- NO MD Assessment
3. NO Anesthesia Consultation
18/07/2015
Admission Scenario (Current)
1. SDA- NO MD Assessment
2. SDCU- NO MD Assessment
3. NO Anesthesia Consultation
MD Assessment belongs
between
PAST SURGICAL HISTORY &
NURSING PREOP PLAN OF
CARE
Admission Scenario (Current)
1. SDA- NO MD Assessment
2. SDCU- NO MD Assessment
3. NO Anesthesia Consultation
Admission Scenario (Current)
1. SDA- NO MD Assessment
2. SDCU- NO MD Assessment
3. NO Anesthesia Consultation
Open
Admission Scenario (Current)
1. SDA- NO MD Assessment
2. SDCU- NO MD Assessment
3. NO Anesthesia Consultation
Understanding the Flow
Encounter and Sessions
Transfer OUT
Preop Session
Transfer IN
Transfer OUT
Intraop Session
Transfer IN
Postop Session
ENCOUNTER (GA)
•From time of admission until time of discharge
Compliance Statements
ANES: Compliance Statements
A030_Milestone-Documentation
• Working with a Resident
– If the resident has been the
one to open the session,
then all entries into the
system will be attributed to
him/her
• Use the SAM button to
gain access to the
Compliance Events and
enter your involvement
with the case
– The resident does NOT
need to log off for you to
use SAM
Compliance Statements
ANES: Compliance Statements
A030_Milestone-Documentation
1. Click on the “SAM”
icon
2. Enter your credentials
Compliance Statements
ANES: Compliance Statements
A030_Milestone-Documentation
•
Default screen that appear is “ALL
EVENTS”
–
(every event in Anesthesia Manager
belongs to a Category defined in the
underlying database)
•Alternatively, you can switch to the
“Event Sets”
-choose Event Set A030
Compliance Statements
ANES: Compliance Statements
A030_Milestone-Documentation
1. Select desired
descriptors and move to
active window,
window click
“OK”
2. Logout of
SAM
Descriptors appear
under your
User ID
SAM events now appear in Main Event
window under your User ID
Compliance Statements
ANES: Compliance Statements
A030_Milestone-Documentation
• Relief
– When you are being
relieved by another
individual, you should “log
off”.
• Screen disappears but
data is still being
captured.
– Relief should “log on” and
document in Event Set
A030_MilestoneDocumentaion
Completing the Anesthesia Record
PACU/SDCU/ICU
•
The anesthetic record is
NOT complete until care of
the patient has been
transferred to the nurses in
PACU
•
On entering the PACU, the
nurses will “Start Session”
the patient on the local
workstation.
•
It has been agreed that all
further Anesthesia
Documentation will be
completed on dedicated
workstations in the PACU/
SDCU using “REMOTE
VIEW”
1. Locate patient in census and
click “Remote View”
Template shows the movement of the patient from the
GA (transfer) session to the GA (PACU Post Op) session
Completing the Anesthesia Record
PACU/SDCU/ICU
3. Select relevant
descriptors and make
ACTIVE, then hit “OK”
2. Hit
Open
theEvent
“Report
Sets
Icon”
(usewhich
icon or
F4) andthe
opens
choose
“Add Events” windowA005_PACU-SDCU-ICU Report
Completing the Anesthesia Record
PACU/SDCU/ICU
•
We now have to
place the “Finish
Time” on the
record
1. Hit the “Finish” iconcurrent time is displayed.
Adjust as appropriate
appropriate.and
hit “OK”
•
We also have to
print the record
(upload to vOacis)
which appears
after the “Finish
Time” has been
entered.
2. Hit the <
icon to
explode
Completing the Anesthesia Record
PACU/SDCU/ICU
• Hitting the < icon breaks the
General Anesthesia Encounter
into its respective sessions:
–
–
–
–
Surgical Pre-Op
GA (Standard) not shown
PACU Post Op
Surgical Post-Op
• Select the GA (Standard)
session
• Hit OK and record is sent
electronically to vOacis
• Logoff Remote View (detailed
instructions to follow)
PACU Progress Notes
• All notation by anesthesia in
the PACU will convert to an
electronic format
1. Pull down Menu-Insert/View,
choose “Patient Summary”
2. Choose “Notes”
PACU Progress Notes
3. Choose “Add Note”
4. Complete Note