Critical Information

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CRITICAL INFORMATION

Phone Numbers

Code Blue or Code Green - 15555

Computer Help Desk - 15519

Bed Flow Coordinators

7am-4pm, M-F: 857-4405; 857-4426

4pm-7am, Weekends, Holidays: AOD at 15162

Transcription

Dictation: 68205

Supervisor 68205

Assistance: 68205

(Call to Activate DUZ)

MICU: 16075; CCU: 14640

4A: 15401; 6B: 14602; 5A: 18878; PCU: 17873

BMTU: 16337; Telemetry (for 5A, 6B, 2W): 14628

SICU: 14573; 2W: 14402

Operating Room desk: 15103

Outpatient Surgery: 16266

PACU: 16265

Surg Resident’s Work Room (2W) 16625, 14418

On Call Roster, copies of “Survival Guide and House Staff Manual: under “Hot Topics”, Audie Home Page

Online Library: Drop down “Tools” from any patient’s CPRS cover sheet.

For Linking Encounters & Consults, or to

Retract progress/other notes, call 14616

COMPUTER CONDUCT

Always lock or logout when you are away from the computer.

Do not let someone use your access codes.

Do not allow someone to use your DUZ or use someone else's DUZ for transcription or other purposes.

Confirm you are in the correct patient's chart before you start writing orders, notes, etc.

Four codes you should know:

Network Access Code & Password

VISTA/CPRS/IMED Access Code & Password

Electronic Signature Code

DUZ Number (if you’re going to dictate, e.g., Op reports; call 68205 to activate)

Passwords

·  Change every 90 days

·  Can’t use previous ones

·  Must consist of 10-16 characters

·  Must include 3 of 4 types of characters

·  Upper case, lower case, number, special

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Guidelines

NOTE TITLES:

Selecting Frequent Note Titles

(You may, and should, add and remove service specific note titles during your rotations, as needed)

Sign in to CPRS, select any patient

Select TOOLS, then OPTIONS

Under OPTIONS, select the NOTES tab

Select Document Titles

Suggested note title additions to your default list:

10-10M/Physician (admit from clinic)

History & Physical Note/Surgery, Medicine or H&P/Psychiatry

Physician Progress note

Procedure Note; Bedside Procedure Note; (your section’s) Clinic Procedure Note (if any)

Preliminary Operative Report

Medicine Reconciliation Note STX

Physician Against Medical Advice

DNR Progress Note

Physician Code Blue

Physician Death Note

GEC Physician/LIP note

Telephone Consent; No-show note

When finished click Apply and OK boxes

Medication Reconciliation Note

TJC and VA have mandated the performance of med reconciliation at every outpatient episode of care, and at admission, transfer of care responsibility, and at discharge for inpatients. It is a reasonable expectation and improves patient adherence.

While med rec at admission and transfer occurs when you embed the lists in your admission/transfer notes (review with patient!), a separate note (“medication reconciliation note”) is required at outpatient visits or inpatient discharges. Filling it out is self-explanatory. Review for completeness. Edit any instructions to make sure they are easily understood and written in plain English. Sign the note and print one copy. Review the copy with the patient and give it to them. If you take the time to do this correctly, you may cut and paste the note at the next visit, carefully document any changes, and sign. This is a routine measure of care.

The Admission Process

*Requires completion of admission orders and H&P.

*Staff Note by end of day after admission.

*“History & Physical/Surgery (or Medicine)” note title. Admission orders should be entered as “Delayed

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Orders”. When prompted, select delayed pending “Admission to XXX”, where XXX is your service.

Admit to (your service); attending and primary physician names.

Diagnosis: (No abbreviations)

Condition: (“Stable” for ward patients, “Critical”, “Unstable”, “Seriously Ill”, for ICU patients.)

Code Status: Full, Limited (with explanation), DNR (DNR orders and note both completed; staff must sign by 24h).

Surgery Date: (if applicable)

Planned Procedure: (if applicable)

Vital signs and other nursing assessments: (Intake/Output, Daily weight, etc.)

Activity: See options. Don’t forget restraint orders if necessary.

Patient Care: Specific nursing care, e.g.: dressing changes, traction, etc.

Diet: enter diet orders and request diet consult if indicated.

Medications: You may highlight Outpatient meds in the meds tab, and use the “Action”, Transfer to Inpatient” options, or write new med orders. Don’t forget IV fluids, IV medications.

Respiratory Therapy Consult (if applicable): order set allows you to request treatments and write for meds.

Laboratory Orders: Pay attention to the collect options. Ward collect means that the ward personnel or you will draw and send. Lab collect means that lab personnel will draw at scheduled times (0600 and 1100). Send Patient to Lab means the patient has to be able to walk down to the lab and wait for personnel to draw the studies.

Special Studies: Complete radiology requests, ECG requests, or appropriate consults to obtain any special studies you may require. Inpatient consults require you page and discuss them with the on-call person for that service.

Anticipated Discharge: Identify a target discharge date and expected discharge location. Assume the best-case possibilities.

THE SURGICAL PROCESS

*Prophylactic antibiotics are service/procedure specific. Ordered by SURGEON, and administered

within one hour of incision time by anesthesia.

*Postoperatively, these antibiotics are continued for no more than 24 hours. After 24 hours, they are no longer considered prophylactic and must have an indication for use in the chart.

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For patients on β-blockers: continue pre- and post -op

* Keep postop blood glucose levels below 200.

* Keep postop patient temp >96.8.

* DVT prophylaxis ordered postop.

Informed Consent. The method for documenting consent is the I-MED Consent (on “Tools” drop down in CPRS) (if no CPRS or IMED is down, ward clerks have written consents at desk). Informed consent should be obtained days to weeks prior to surgery. A signed form is good for 30 calendar days.

To use IMED consent, you must be the individual logging onto the network and to CPRS.

To open a new consent form or a previously saved one awaiting signature, go to the tools tab in CPRS, and drop down to IMED consent. Double click to open it. If looking for a previously written consent, look on the left for “saved forms without signatures”. Click on the appropriate form.

If opening a new consent, select the appropriate specialty by clicking on the + sign next to the specialty. For most procedures, select “Consents-Basic” and then look at the actual list. Select all procedures that apply. Then select Begin Consent in the lower right corner.

Verify/complete the info on the Verification page.

Complete the Condition or Diagnosis page.

Identify anatomical location and side/laterality in clear language.

Note anesthesia’s involvement.

Blood consents: Find in “basic” menu for almost any specialty, but also, for surgery, there are 3 options (all within surgery consent); pick one. If they do not wish to consent to blood usage, please check with your staff for further guidance.

List yourself as the signing practitioner. Identify the attending staff and any additional individuals who may possibly be involved with the case.

After clicking OK, the computer will present you with a consent form for review.

Best Practice: print the form for patient review and have them read it until your attending has a chance to meet with them.

You may “sign” now, or “hold for signature”.

When all discussions are completed, obtain appropriate signatures and then click “Save to Chart.” If you don’t do this, your consent form goes away!

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The form is saved and available for viewing in its entirety through VISTA Imaging. It’s also viewable in the progress notes section of CPRS.

Telephonic Consent

On occasion, the patient may not be able to consent for themselves due to illness, injury, or altered mental status. The surrogate may only be available via telephone. The process for obtaining telephonic consent is as follows:

(1) Dial the next-of-kin/Guardian or surrogate.

(2) Discuss the details of the proposed procedure, answer all questions, and explain consent will be electronically recorded.

(3) Once the individual agrees to the procedure and recording of the consent, have the family member remain on the line and proceed as follows:

(a). Press tab or flash to place on hold or use transfer.

(b) Dial 13101 if calling from inside the hospital or 949-3101 if calling from outside the hospital.

(c) When the digital dictation system answers, enter your DUZ or authors five digit identification number.

(d) Enter work type “14”, and enter the patient’s nine digit Social Security number.

(e) Press the tap or flash button to connect a family member. On multiline telephones, press CONF.

(f) Enter “4” to begin recording.

(g) Conduct the telephonic consent as below:

"This conversation is being recorded. Do you have any objections? (Yes/no).

This is Dr. (your name) at the Audie L. Murphy Campus of South Texas Veterans Health Care System, San Antonio, Texas. The date is (_____) and the time is (_____).

I am talking to (name of relative), the nearest relative of (patient name).

Mr. or Mrs. (name of relative), will you please state your full name and full relationship to (name of patient).

(Allow surrogate to answer).

I have discussed your granting this hospital permission to perform (description of the operation or procedure in layman’s language) on (patient name). The attending Physician will be ___ and the residents involved will be ______.

Do you grant your permission for this operation to be performed? (Yes/no).

Do you consent to any blood product usage deemed necessary? (Yes/no).

Do you wish to state an objection or reservation or exception? (Yes/no).

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(You and/or the surrogate may enter any other comments at this time)."

After the party being phoned is finished, have them hang-up, and key in the “*1” before replacing the receiver. This marks the dictation as STAT.

To verify recording of the consent, access the listen line. Dial extension 13101 or 949-3101. Enter your DUZ number. Enter “*1” to access the listen line. Enter the patient’s nine digit Social Security number and press “1” to listen to the consent.

The typed transcript of the recorded telephone consent, electronically signed by the transcriptionist stating that it is an accurate verbatim transcript of the conversation, will be forwarded for electronic signature to the physician who obtained consent.

Emergencies.

In the event the patient is unable to give consent, and the party who has the authority to grant consent is not available or nonexistent, authority may be granted by the Chief of Staff or two staff physicians for emergency procedures. A written progress note must then reflect consent inability, and danger of no surgery/procedure. Notify Service Chief (has to review and sign).

Preoperative Assessment

Regardless of the location of the preoperative assessment, whether it is inpatient or outpatient, certain components must be completed prior to taking a patient to the operating room.

*First, all patients must have active orders, which include a diagnosis, the proposed surgical procedure and date, and any prophylactic antibiotics that should be administered.

*Second, all patients must have a valid consent for surgery, and for blood products. This consent must have been signed within the previous 30 days.

*They must have a complete history and physical that is less than 30 days old.

*DOSA & OPS patients with an Admission note from more than 24 hours prior must have a Day of Admission/Surgery note.

*The attending surgeon, who will perform the operation, must have a recent staff note, in the chart, before surgery.

*Appropriate preoperative studies (will vary by procedure) must have been accomplished with results noted in the chart.

*Patients who normally take metformin should stop that at least 48 hours prior to undergoing general anesthesia.

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***On the day of surgery, the staff surgeon will verify the identification of the patient, accomplish the Day of Admission/Surgery note and mark the surgical site in accordance with the correct site policies.

Patient Procedures outside the Operating Room.

Any invasive procedure performed outside the operating room, should be consented. The procedure is the same as that for operative procedures. Once informed consent is obtained, the patient should be identified, and the correct site verified. The correct site should be marked.

Document these procedures by completing either the Surgical Procedure Note in the CPRS notes section. This note should include a discussion of the identification verification, obtaining informed consent, correct site marking and verification, and should then describe briefly the procedure. The note should include how well the procedure was tolerated and outcome. Identify specimens sent to the lab.

Documenting Surgical Procedures.

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Nationally, the standard of care requires a written surgical report be included in the patient’s chart immediately (at Audie, 30 minutes) after surgery.

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The Immediate Post-Op Note allows the surgeon to communicate the essential information regarding intraoperative care as part of a hand-off process. It should be completed prior to leaving the OR, but MUST be done within 30 minutes of the patient leaving the OR.

The Immediate Post-Op Note MUST contain: 1. Pre-Op dx; 2. Post-Op dx; 3. Technical procedures used; 4. Surgeons; 5. Anesthesia; 6. Blood loss; 7. Findings; 8. Specimens removed; 9. Complications; 10. Plan. If appropriate, add: 11. Drains and 12. Tourniquet time.

The surgeon of record may dictate the op report using dictation services. You will receive an alert when the report has been transcribed. You may then open and

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review the report, make corrections, and then sign the report. Once signed, no one can make corrections to the text. Should you or your staff want to change anything, you must enter as an addendum. Your attending surgeon will then cosign the report.

Postoperative Care.

Remember that post op orders must be written as delayed, or written as active after the stop time for the procedure is entered by the nurse in the OR.

Pay attention to maintaining normothermia, tight glucose control, deep venous thrombosis prophylaxis, the evaluation and skin integrity, and the appropriate use of prophylactic antibiotics. These prophylactic antibiotics should not be administered beyond 24 hours following surgery.

Postoperative patients will recover in the PACU or in the SICU. From the PACU they may return to outpatient surgery for discharge, or they may be moved to the surgical ward on 2W as observation or inpatient admissions. The prudent physician will reassess his written orders following patient movement to that unit.