PACU PRE-OP. Demographics

Transcription

1 Table of Contents Can you find this information that the Joint Commission will ask to see? Remember there may be multiple paths to locate the below information. Any route that you know will be fine! PRE-OP Demographics o Race and Ethnicity o Preferred Language Education o Learning Needs o Patient Education Nursing Assessments/Documentation o Initial/Ongoing o Alarm Settings o Plan of Care o Psychosocial (includes End of Life Care) o Social (includes alcohol, substance and tobacco abuse) o Immunizations o Nutritional/Hydration Status o Functional Screen o Fall Risk o Abuse/Neglect o Suicide Risk o Pain Assessment/Reassessment o Advance Directives OR ANY OTHER LEGAL DOCUMENTS (POA, Custody Papers) Physician Documentation o History and Physical o Consult Notes o Authentication of Orders Medication o Medication Reconciliation on Admission, Discharge or Transfer o Clarity of Orders PACU Demographics o Race and Ethnicity o Preferred Language Education o Learning Needs o Patient Education Nursing Assessments/Documentation o Initial/Ongoing o Alarm Settings o Plan of Care o Psychosocial (includes End of Life Care) o Social (includes alcohol, substance and tobacco abuse) o Immunizations o Nutritional/Hydration Status o Functional Screen o Fall Risk o Abuse/Neglect o Suicide Risk o Pain Assessment/Reassessment o Advance Directives OR ANY OTHER LEGAL DOCUMENTS (POA, Custody Papers) Physician Documentation o History and Physical o Consult Notes o Authentication of Orders Medication o Medication Reconciliation on Admission, Discharge or Transfer o Clarity of Orders 1

2 Table of Contents Can you find this information that the Joint Commission will ask to see? Remember there may be multiple paths to locate the below information. Any route that you know will be fine! PRE-OP (continued) Procedural Documentation o Informed Consent o Pre-Anesthesia Assessment o Immediate Pre-Induction Assessment o Pre-Procedure Checklist o Timeout o Immediate Post-Op Note o Post-Anesthesia Assessment Legal Documents ( POA, Custody Papers) Restraint Documentation o Orders o Monitoring o Inclusion in Plan of Care PACU Procedural Documentation o Informed Consent o Pre-Anesthesia Assessment o Immediate Pre-Induction Assessment o Pre-Procedure Checklist o Timeout o Immediate Post-Op Note o Post-Anesthesia Assessment Legal Documents ( POA, Custody Papers) Restraint Documentation o Orders o Monitoring o Inclusion in Plan of Care 2

3 APPENDIX You are asked to pull up a patient who had surgery on a previous date and the patient is discharged. The surveyor only provides you with a patient s Medical Record Number. How will you pull up that patient to begin the review? Patient Lookup > enter MRN > Find Patient > highlight and Select patient > Encounters > select desired Encounter 1

4 APPENDIX You are asked to pull up a patient who had surgery on a previous date but they are still admitted. The surveyor only provides you with a patient s Medical Record Number. How will you pull up that patient to begin the review? Note that this functionality will also work using a patient s name who is an inpatient. Patient Lists > enter MRN and click magnifying glass > double click on patient to open chart 4

5 DEMOGRAPHICS RACE & PREFERRED LANGUAGE Status Board > double click on patient to open chart > click on bolded patient name > Clinical Information

6 DEMOGRAPHICS ETHNICITY Status Board > double click on patient to open chart (as above) > click on bolded patient name > Contact Information

7 EDUCATION LEARNING NEEDS More > Education > view Learning Assessment 7

8 PATIENT EDUCATION PATIENT EDUCATION More > Education > All > view Education (orange circular arrows mean educational title not complete; green circle with white check means education resolved; white circle with green check means education initiated, not yet resolved) 8

9 NURSING ASSESSMENTS/DOCUMENTATION INITIAL/ONGOING Pre-Op Looking for Inpatient Assessment(s) Flowsheet > Pre-Op Assessment > pull bottom scroll bar to left to view inpatient assessment(s) 9

10 NURSING ASSESSMENTS/DOCUMENTATION INITIAL/ONGOING PACU Looking for Inpatient Assessment(s) Flowsheet > pull bottom scroll bar to far left (initial inpatient assessment) > pull scroll bar to right to view subsequent inpatient assessments 10

11 NURSING ASSESSMENTS/DOCUMENTATION INITIAL/ONGOING PACU Looking for Pre-OP Assessment on an Inpatient Flowsheets > Pre-Op Assessment > drag tool bar to start of the encounter CONTINUED. 11

12 NURSING ASSESSMENTS/DOCUMENTATION ALARM SETTINGS PACU Alarm Settings Phase II/III navigator > Head to Toe > Vitals > Alarm Parameter 12

13 NURSING ASSESSMENTS/DOCUMENTATION PLAN OF CARE Pre-Op or PACU navigator > Care Plan > Care Plan (either pre or post procedure will display)

14 NURSING ASSESSMENTS/DOCUMENTATION PSYCHOSOCIAL ASSESSMENT (INCLUDES END OF LIFE CARE) Flowsheets > Psychosocial > Last Filed

15 NURSING ASSESSMENTS/DOCUMENTATION SOCIAL ASSESSMENT (includes alcohol, substance, and tobacco abuse) Chart Review > SnapShot > Pt Sum > scroll to locate Social History/Documentation 15

16 IMMUNIZATIONS Chart Review > ShapShot > scroll to Immunizations/Injections NURSING ASSESSMENTS

17 NURSING ASSESSMENTS Nutritional/Hydration Status Flowsheets > Fluid/Nutrition All > Last Filed (this information may pull over into patient summary as well. Chart Review > SnapShot > Patient Summary

18 NURSING ASSESSMENTS FUNCTIONAL STATUS (ADLs) Chart Review > SnapShot > Pt Sum > scroll to Activities of Daily Living

19 NURSING ASSESSMENTS FALL RISK PRE-OP AREAS Chart Review > Index > SBAR Handoff > scroll to Assessment > Fall Risk (Fall Risk is also found right on the Flowsheets as well)

20 NURSING ASSESSMENTS FALL RISK (currently being looked at by Dee B.) PACU AREAS Chart Review > look to right of screen > Fall Risk > Fall Risk information opens below (Fall Risk is also found right on the Flowsheets as well) 20

21 NURSING ASSESSMENTS/DOCUMENTATION SUICIDE RISK Flowsheets>click on magnifying glass>enter suicide risk >Search>Accept

22 NURSING ASSESSMENTS ABUSE AND NEGLECT Flowsheets > click on magnifying glass > enter screenings > search > select Screenings IP Screenings > Accept > Psychosocial > click on double chevrons > Domestic Vi 22

23 PAIN ASSESSMENT/REASSESSMENT PAIN ASSESSMENT/REASSESSMENT Chart Review > Index > Medications Category > Pain Monitoring 23

24 ADVANCED DIRECTIVES ADVANCE DIRECTIVES TO IDENTIFY IF PATIENT HAS AN ADVANCE DIRECTIVE Status Board>double click to open chart>click on bolded patient name>advance Directives 24

25 ADVANCED DIRECTIVES ADVANCE DIRECTIVES (To locate the actual Advance Directive) TO LOCATE AND VIEW ACTUAL ADVANCE DIRECTIVE OR ANY OTHER LEGAL DOCUMENTS (POA, Custody Papers) Chart Review>Media Click next to Document Type to alphabetize all Media/scanned documents 25

26 HISTORY AND PHYSICAL Chart Review > notes > scroll to locate H&P PHYSICIAN DOCUMENTATION Click next to Type to alphabetize all notes 26

27 PHYSICIAN DOCUMENTATION CONSULT NOTES Chart Review > Notes > scroll to locate Consultation Notes Click next to Type to alphabetize notes 27

28 PHYSICIAN DOCUMENTATION AUTHENTICATION OF ORDERS Orders > Active Orders > select order in question > Order Report and select order in blue hyperlink > scroll to see Order details 28

29 MEDICATIONS HOME MEDICATION RECONCILIATION ADMISSION Pre-op Navigator>Home Medications At the very bottom of the Home Med, you will see who last updated the list and when 29

30 MEDICATIONS HOME MEDICATION RECONCILIATION TRANSFER Phase II/III Navigator > Phase III > Med Rec Status 30

31 MEDICATIONS HOME MEDICATION RECONCILLIATION DISCHARGE Phase II/III navigator > Phase II > Med Rec Status 31

32 MEDICATIONS CLAIRITY OF ORDERS MAR > click on white area of MAR > View med order specifics CLICK 32

33 INFORMED CONSENT Chart Review > Media > select desired consent PROCEDUREAL DOCUMENTATION Click next to Document Type to alphabetize all Media/Scanned documents 33

34 PROCEDURAL DOCUMENTATION PRE-ANESTHESIA ASSESSMENT & IMMEDIATE PREINDUCTION ASSESSMENT Status Board > single click on patient > Anesthesia Record > Anesthesia Record opens > scroll down to Preprocedure Note AND/OR Immediate Preinduction Assessment FROM WITHIN PATIENT S CHART (No screenshots included) Chart Review>Encounters>locate and single click on desired Anesthesia Event>Anesthesia Record opens to right>scroll opens>scroll down to Preprocedure Note (If not able to see right panel, slide to left to open window) 34

35 PROCEDURAL DOCUMENTATION PRE-PROCEDURE CHECKLIST FROM PRE-OP Pre-op navigator > click on Checklist 35

36 PROCEDURAL DOCUMENTATION PREPROCEDURAL CHECKLIST FROM PACU Phase II/III navigator > More > Preop navigator > click on Checklist

37 PROCEDURAL DOCUMENTATION TIMEOUT More > Intraop > Timeout

38 PROCEDURAL DOCUMENTATION IMMEDIATE POST-OP NOTE Chart Review > Notes > Brief Op Note Click by Type to alphabetize notes 38

39 PROCEDURAL DOCUMENTATION POST-ANESTHESIA ASSESSMENT Status Board > Anesthesia Record > Anesthesia Record opens > scroll down to All Postprocedure Notes

40 RESTRAINT DOCUMENTATION Orders Orders > click on restraint order > select Order Report > displays order details/questions 40

41 RESTRAINT DOCUMENTATION MONITORING Preop or Phase II/Phase III Navigator > Head to Toe > select FALLS/SAFETY ALL > scroll to Safety (Please note that as of now, Restraint documentation is only in the PACU Flowsheet; ticket was placed on 2/9 to add to Preop Flowsheet as well. Will add screenshots when changes are made. Restraint monitoring is also not added and user needs to add that particular flowsheet as demonstrated below for now. This too was requested to be added) Preop or Phase II/Phase III Navigator > click on magnifying glass > type in restraint > click search > select type of restraints > Accept

42 RESTRAINT DOCUMENTATION MONITORING FROM PACU Phase II/Phase III Navigator > Head to Toe > select FALLS/SAFETY ALL > scroll to Safety (Please note that as of now, Restraint documentation is only in the PACU Flowsheet; ticket was placed on 2/9 to add to Preop Flowsheet as well. Monitoring IS NOT yet included and will need to be accessed as demonstrated on slide 29)

43 RESTRAINT DOCUMENTATION MONITORING (This is being added to both Preop and Phase II/Phase III Head to Toe under Safety) To view details of Performed Safety Monitoring, click on the cell If Row Information box does not show, the side panel may need to be opened by clicking on either of the two arrows 43

44 RESTRAINT DOCUMENTATION INCLUSION IN PLAN OF CARE Currently, there is no inclusion in OpTime. If asked by TJC, point out the Performed Safety Monitoring information in previous screen. 44