Fellow Orientation: Documentation Linda Le-Wendling & Kiki Nin

Content Orders: Pre-procedural Post-procedural Pre-procedure forms Consent Preop completion Procedure note Time out Process: Quality form Round Progress note Routine notes 24 hour check notes Telephone follow-up note Consult note Ad-hoc block

Find pt on Snapboard Highlight, then Right Click – must do when logged in as “attending” Click “Open Case” Change to Block When you decide that the patient will go to the block room prior to surgery, you must change the Anesthesia Type on the SnapBoard.

Orders: Pre-procedural orders Before starting please make sure you place your “Regional Anesthesia Block Pre-procedure Order Set” before doing your block so that the nursing staff can pull the sedation drugs if it applies to your case.

Make sure you order pre-procedural ropivacaine bag with your order set

Order ropivacaine bag (cont): make sure you note type of catheter

Prior to block (See next group of slides) Make sure that consent form for both surgery and anesthesia is signed and witnessed Make sure that the Anesthesia H&P, if performed by an RN, should be completed. If there is no Anesthesia Preop, you must do one prior to block Make sure that EPIC is capturing vital signs (Device is added to the EPIC chart) Click block start prior to proceeding with the block.

Anesthesia consent form All consent forms must be done within one month of surgery Remember to check all anesthetic types that apply For Regional Anesthesia section, the location and side of the block MUST be spelled out clearly. Do NOT use any abbreviations. E.g. do not write L UE, write out left upper extremity Do not write the type of block to be done, only the location to be anesthetized

Doing a block on EPIC Find the patient on All Cases or under South Tower or press “CONTROL + F” and search for patient’s last name.

SINGLE click on the patient’s name and open the IntraOp activity.

Do NOT assign staff when doing a perioperative block. You will document anesthesia staff for the block later within the body of the procedure note.

Pick your Macro: “Periop Block.”

Manually attach your device, click the “More” button in the toolkit at the bottom/left of the screen, then click “Device.”

You then need to manually add the correct device in the drop down menu below, and click “Add.” At North Tower: Look at the top left hand corner of the monitor and get the letter combination At South Tower: UA “plus the numbers at the top of the room number” At FSC: BLK ”room number” PRESS SEARCH ALL FIRST!!!!!

To confirm the device is capturing data, the border of the vitals section will turn white/grey and colored markings will start to appear on the grid

Start out of OR Vitals Click “Block Start” in the quick events panel - please click on this after time-out so that the OR has a live feed.

Marking the patient’s limb Should be done by an attending or a fellow An “A” circumscribed by a circle must be placed on the limb to be blocked, on the side to be blocked if surgery is on the trunk or pelvis. Must be viewed easily when the patient is positioned for the block A

Remember that the time out process must be complete, all individuals performing the block must be present (nurse, trainee, faculty)

You MUST do another time out when: You change the patient’s position E.g. you did sciatic block lateral or prone and now switch to supine for femoral or adductor canal block This is where we have had wrong-sided blocks When you change plans E.g. difficult epidural, now proceeding with paravertebral

After the procedure is done, click ‘block end’ and write the procedure note (next few slides)

Click “Block End.”

Open Procedure Note activity in the Toolkit, and choose the correct block note. If doing more than one block (femoral and sciatic single shot) you must complete a procedure note for each block.

BEST PRACTICE WORKFLOW: The bedside RN will be documenting the sedation meds (except propofol or ketamine) separately in the Medication administration record (e.g., the MAR). Perform your procedure and then complete the procedure note—Click, click, click……This is where you will document the supervising anesthesiologist and person performing the block as well.

Intraoperative Record Criteria to Bill for a Regional Block Seperately:Service must be requested Proper diagnosis indicated Post op pain (338.18) Pain from trauma (338.11) Thoracotomy pain (338.12) Done for postoperative pain, not intraoperative anesthesia Can’t be separate if billed separately as MAC intraoperatively You cannot click both intra-op pain and post-op pain for diagnosis If you click block indication is for post-op pain, then the intraoperative anesthesia should be ‘General’ If you click intraoperative anesthesia as MAC, the the block indication should be intraoperative pain (usually when doing single injection blocks with short-acting agents such as lidocaine counts)

EPIC: Anesthesia type

Block Note

Make sure you write post- procedural orders on the patients

LEAVE MONITORS ATTACHED until patient leaves for OR. The Anesthesiology staff transporting the patient to the OR will click “STOP OUT OF OR VITALS!”

Make sure you add the patient to the APS list for follow-up 1 2 3

Daily Routine There will be a MASTER LIST of all the block patients for the day with 4 checkmarks to be completed after the block. Orders List (EPIC) Note (Procedure note on EPIC intraop screen) Attending Attestation

Daily Notes Post op days notes should be sent to the attending rounding NT attending will round on the NT, ST 4 th floor, 5 th floor and other floors The ST attending will round on the 6 th floor and some busy days on the 5 th floor APS 3 attending will round on joint and ERAS patients POD 0 notes do not require attending co-sign POD 1 require co-sign

Go to the patient’s chart and go to Notes. Click on New Note

Progress Note Type: Progress Note Click on the Smart Text

When you select place under FAVORITES

Rounding: Progress Note When doing notes please make sure you place on the top of the note (see below) APS Attending--> the name of the attending that you are sending the note to cosign. DO NOT put "see cosigner" because the billing people can't find who you sent it to.

Note is self explanatory Important things to mention: APS Attending POD and Catheter day Make sure daily updates of sensory/motor exam CAREFUL WITH COPY AND PASTE!!!

For single injections, If the patients are in house the following day, a POD#1 note should be written with the following information: When did the block recede? Is the patient’s pain controlled with systemic analgesics? (May consider offering continuous catheter) These progress notes are for documentation and process improvement, not for billing purposes.

Home Catheter Notes Go to your Patient List

Double click on the patient and go to More Activities

Go to Encounters and click on Phone Fill out the Provider as well as the Department as shown below.

Fill out reason for phone call  PAIN and press Close Pain

Click on the documentation area and type.aps and the note below will show up.

The note will appear as follow. Please fill out all the areas with ***. The green fields will be a drop down menu the same as the paper records. This drop down has also an option at the end (***) for you to be able to write a couple of sentences as comments. These comments can include infusion volume, plan for removal, etc.

At the end please choose sign on close

Click on Close Encounter

AdHOC blocks These procedures are done when the block is the only reason for admission Epidural blood patch after discharge Patients with single injection blocks discharged from service and now with significant pain requiring readmission for nerve block The next group of slides will show you how to admit the patient under our service without need of the surgical services.

Ad-hoc blocks Blocks not associated with a surgical encounter or patients not admitted. If it’s a patient coming from home for blood patch ask patient to proceed directly to south tower lobby and call APS at DO NOT CHECK IN TO ADMISSIONS Do NOT stop ambulatory, ED, Pre-Op, OB, or anywhere else!

Ad-hoc block for patient admitted and no surgical encounter

ASSIGN STAFF (both attending and fellow/resident) when doing a block on a patient that will NOT be going to the operating room.

Pick your Macro: “Ad Hoc Block.” Notice that in this macro, meds are available for you to document.

Click “Anesthesia Start” in the Quick Events panel.

Manually attach your device: click the “More” button in the toolkit at the bottom/left of the screen, then click “Device”.

You then need to manually add the correct device in the drop down menu below, and click “Add.” At North Tower: Look at the top left hand corner of the monitor and get the letter combination At South Tower: UA “plus the numbers at the top of the room number” At FSC: BLK ”room number” PRESS SEARCH ALL FIRST!!!!!

Start our of OR Vitals

Open the Procedure Note activity in the Toolkit, and choose the correct Block Procedure note.

If it’s an epidural blood patch done in the ER and there is no nursing staff to get the sedation drugs you will have to chart the medications yourself on the intraop section.

Perform your procedure and then fill out the procedure note—Click, click, click……This is where you will document the supervising anesthesiologist and person performing the block as well.

Stop Out of OR Vitals

Click Anesthesia Stop

Please make sure that you complete the “type performed” as seen below. Make sure you finish the post anesthesia procedures (aldrete, post op note and close encounter)

Chart paperwork Ask block room or PACU clerk to print chart paperwork/stickers/bracelet. Patient must sign the consent and authorization for treatment form (white/yellow paper) found in the block room front desk

Adhoc Block(any block not linked to an OR case) Major differences for Ad-Hoc Block: You will need to chart all sedation and local anesthetics given under intraop record if in location other than block room or PACU. You will need to ASSIGN YOURSELF AS STAFF, just as if you were in the OR. You will need to attest to ONLY the procedure (block). There are no “BLOCK START” or “BLOCK END” events; they are replaced with “ANESTHESIA START” and “ANESTHESIA END” times because these procedures are time-based billable items.

Before starting please make sure you place your “Regional Anesthesia Block Pre-procedure Order Set” before doing your block so that the nursing staff can pull the sedation drugs if it applies to your case.