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 Admission Scenario (Current) 1. SDA-MD Assessment 2. SDCU-MD Assessment 3. Anesthesia Consultation 19/08/2019

Admission Scenario (Current) 1. SDA-MD Assessment 2 Admission Scenario (Current) 1. SDA-MD Assessment 2. SDCU-MD Assessment 3. Anesthesia Consultation 19/08/2019

Admission Scenario 1. SDA-MD Assessment 2. SDCU-MD Assessment 3 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 Admission Scenario (Current) 1. SDA- NO MD Assessment 2. SDCU- NO MD Assessment 3. NO Anesthesia Consultation 19/08/2019

Admission Scenario (Current) 1. SDA- NO MD Assessment 2 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 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 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 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 Transfer IN Transfer OUT Transfer IN Preop Session Intraop Session 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

2. Enter your credentials 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 Descriptors appear under your User ID 1. Select desired descriptors and move to active window, click “OK” 1. Select desired descriptors and move to active window SAM events now appear in Main Event window under your User ID 2. Logout of SAM

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_Milestone-Documentaion

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” 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” 3. Select relevant descriptors and make ACTIVE, then hit “OK” 2. Hit the “Report Icon” which opens the “Add Events” window- A005_PACU-SDCU-ICU Report 2. Open Event Sets (use icon or F4) and choose A005_PACU-SDCU-ICU Report

Completing the Anesthesia Record PACU/SDCU/ICU We now have to place the “Finish Time” on the record We also have to print the record (upload to vOacis) which appears after the “Finish Time” has been entered. Hit the “Finish” icon-current time is displayed. Adjust as appropriate and hit “OK” Hit the “Finish” icon-current time is displayed. Adjust as appropriate. 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 Pull down Menu-Insert/View, choose “Patient Summary” 2. Choose “Notes”

PACU Progress Notes 3. Choose “Add Note” 4. Complete Note