Electronic Signature for Operative Reports Joy Pasternock EVS, HDS Scott Ridings EVS, HDS

Objectives Provide an Overview Review Installation & Site Parameters Review Signing Operative Reports

Overview

Provides the ability to electronically sign operative reports contained within the VISTA Surgery application. Provides the ability to view these signed reports on the Surgery Tab in CPRS by storing them in the Text Integration Utilities (TIU) package. Surgery Electronic Signature Enhancements

Reports Operation Report Nurse Intraoperative Report Anesthesia Report Procedure Report (Non-O.R.)

Summaries are signed using the Surgery tab or TIU functions Cannot be signed using options within the Surgery package Surgeon is legally responsible for signing the dictated Operative Summary section of the Operation Report Operation and Procedure (Non-O.R.) Reports

Nurse Intraoperative Report and Anesthesia Report Comprised primarily of information contained in specific fields entered through the Surgery package as opposed to a dictated summary Signed using Surgery options only Cannot be signed directly from the Surgery Tab Uploaded into the TIU software upon signature –Viewable on the Surgery tab within CPRS

Nurse Intraoperative Report and Anesthesia Report Addenda Addenda for these reports are also created solely within Surgery options Controlling the process within Surgery options –Signed report and information contained within the Surgery files remains the same

Installation and Site Parameters

Installation of the Surgery Enhancement Surgery patch (SR*3*100) provides the Electronic Signature for Operative Reports enhancements Prior to installing the patch, several setup issues need to be resolved

The Text Integration Utilities patch TIU*1*112 must be installed prior to the Surgery patch (SR*3*100) The document definitions for the Operation Reports defined using the TIU options Requirements Prior to Installation

Worksheet Completion Worksheet is provided with the Installation Guide Completed by the Surgery Application Coordinator with input –Clinical Application Coordinator –Other key Surgery staff Provide completed worksheet to IRM installer Do not install the Surgery patch without a completed worksheet

New Surgery Parameter Determine if your Medical Center Uses the Anesthesia Report New Parameter –‘ANESTHESIA REPORT IN USE’ Prompted during installation Changed after installation –Use the Surgery Package Management Menu Values –No – Default –Yes

Default Clinic for Documents One of the new site parameters included with this patch is the DEFAULT CLINIC FOR DOCUMENTS parameter. –This non-count clinic will be the location passed to TIU, and is used to establish an encounter when Surgery documents are created if no other location can be identified. Enter this parameter immediately following patch installation using the Surgery Site Parameters (Enter/Edit) option. –Before entering this parameter, it may be necessary to create an active, non-count clinic in the HOSPITAL LOCATION file (#44), if a suitable one does not already exist. The default clinic will ensure that each surgery document will be linked to a clinic in the same division where the surgery occurred. –It is recommended that multidivisional facilities define a clinic for each Surgery Site defined in the SURGERY SITE PARAMETERS file (#133) to ensure document linkage to the proper division.

Converting Reports Identify existing cases that should be electronically signed using the new software Determine which reports for existing cases will be viewable through CPRS, but not electronically signed Update cases created with the Boston Class III software

Determine Existing Cases that should be signed using the New Features During installation –Identify existing Surgery cases that will have reports electronically signed using the new features provided by the Electronic Signature for Operative Reports enhancement

Existing Cases Electronically Signed using New Features All reports for all completed cases within the date range selected are included –Case already has an uploaded surgeon’s dictation –Signed paper copy of the Operation Report All associated operative reports will require electronic signature for that case

Enter the Starting Date for Reports to be signed electronically: 05/01/04 During the Post-Installation process, all reports for cases with an operation date on or after MAY 1, 2004 will be identified to be signed electronically. Converting Reports

Benefits Convenience to users –Ability to electronically sign vs. wet signature –Eliminates searching down paper copies Provides a practical medical record –Easier to locate reports Medical Record reviews JCAHO visits –Eliminates dual system Consistent method for signing & viewing reports similar to other TIU documents

Disadvantages Some Reports already signed on paper will now also require an electronic signature Additional upload of previously authenticated documents Staff members may have left facility –Business Rules to allow COS or Service Chief to sign

Making Reports for Existing Cases Viewable through CPRS Determine beginning date to include/view cases prior to installation Consider the reports to include –Operation Report –Nurse Intraoperative Report –Anesthesia Report –Procedure (non-or) Report Complete the Worksheet

Enter the Starting Date for Reports to be moved: 01/01/1995 Do you want to move the Operation Reports? NO// YES Do you want to move the Nurse Intraoperative Reports? NO// YES Do you want to move the Anesthesia Reports? NO// Do you want to move the Procedure(Non-O.R.)Reports? NO// During the Post-Installation process, the following reports will be moved for the date range January 1, 1995 through May 1, 2004: Operation Report Nurse Intraoperative Report

New Option in Surgery Software – Make Reports Viewable in CPRS – Allows moving additional reports for other date ranges after installation of the software New Surgery Package Management Menu Option

Make Reports Viewable In CPRS CAUTION!! –This is a system intensive process that creates new documents in TIU –Please ensure adequate disk space availability before running this process. –Late activity messages may be suppressed by disabling the mail group defined as the "Late Activity Mail Group" while this process runs. This mail group must be re-established after completion

Disclaimer Shown when displaying reports for existing cases that have not been electronically signed Alerts the reader that the information was not electronically signed

Disclaimer Text “This information is provided from historical files and cannot be verified that the author has authenticated/approved this information. The authenticated source document in the patient’s medical record should be reviewed to ensure that all information concerning this event has been reviewed or noted.”

Converting Reports Created with the Boston Class III Software Boston VA Class III Software Automatically converted to the new format during the installation of the Surgery patch Viewable through the Surgery tab and not Progress Notes

Electronically Signing Operative Reports

Signing/Editing Operative Reports Operation Report and Procedure Report (Non-O.R.) –CPRS GUI / Surgery Tab –TIU Nurse Intraoperative Report and Anesthesia Report –VistA Surgery Package

Procedure Report (Non-O.R. ) New field added to the Edit Non-O.R. Procedure option –Determines whether a Procedure Summary gets created for this specific case –Values No Entry (Null) - no summary will be created YES - the process for creating a summary will be similar to the Operation Report process explained in the following slides

Operation Report TIME PAT OUT OR –Time patient leaves operating room – A stub entry for the Operation Report is created within the TIU package Stub

Operation Report Ready for Signature Dictated & transcribed Uploaded into TIU TIU parameter settings determine when view alert is sent to surgeon/attending –Release of documents –MAS Verification –Signature Requirements –Co-Signers Alert signals Operation Report is ready for signature

TIU Parameters REQUIRE RELEASE: –Determines whether the person entering the document is required (and prompted) to release the document from a draft state upon exit from the entry/editing process –Values No Yes

TIU Parameters cont. REQUIRE MAS VERIFICATION: –Determines whether verification by MAS is required, prior to public access and signature of the document –Values NO YES, ALWAYS – Documents require verification regardless how they originate Upload Only – Require verification when documents are uploaded Direct Entry - Verification is required only when documents are entered directly into VISTA

TIU Parameters Cont. REQUIRE AUTHOR TO SIGN: –Indicates whether or not the author should sign the document before the expected cosigner (attending) –Values No –Only the expected cosigner is alerted for signature –Unsigned document appears in the author's unsigned list, and is ALLOWED to sign it, signature is not REQUIRED Yes –author is alerted for signature –If the expected cosigner should attempt to sign the document first, they are informed that the author has not yet signed

TIU Parameters Cont. SEND COSIGNATURE ALERT: –Controls the sequence in which alerts are sent to the expected cosigner of a document –Values After Author has SIGNED Immediately

Notification for the Operation Report Displays the report is ready for signature Selecting the alert –Takes Surgeon to CPRS/Surgery tab The following slide display shows the unsigned Operation Report

Operation Report After signature –Operation Report viewable on the Surgery tab to other users

Signing the Nurse Intraoperative Report and Anesthesia Report Process is the same –Uses data elements within Surgery package Reports can only be signed within VistA Surgery functions

Notification to Sign Nurse Intraoperative Report TIME PAT OUT OR –The time the patient leaves the operating room is entered –Notification is sent to Circulating Nurse that the Nurse Intraoperative Report is ready for signature Acting on the alert –Nurse taken to the Nurse Intraoperative Report option within the Surgery package –Report Options Display Print Edit Electronically sign

Nurse Intraoperative Report Required Fields TIME PAT IN OR TIME PAT OUT OR Count Related Fields (if COUNTS VERIFIED BY has been entered) MARKED SITE CONFIRMED PREOPERATIVE IMAGING CONFIRMED TIME OUT VERIFIED

VeHUPatient, One ( ) MEDICAL RECORD NURSE INTRAOPERATIVE REPORT - CASE # PAGE 1 Operating Room: WX OR3 Surgical Priority: ELECTIVE Patient in Hold: FEB 12, :30 Patient in OR: FEB 12, :00 Operation Begin: FEB 12, :58 Operation End: FEB 12, :10 Surgeon in OR: FEB 12, :55 Patient Out OR: FEB 12, :15 Major Operations Performed: Primary: MVR Other: ATRIAL SEPTAL DEFECT REPAIR Other: TEE Wound Classification: CLEAN Operation Disposition: SICU Discharged Via: ICU BED Press to continue, 'A' to access Nurse Intraoperative Report functions, or '^' to exit: A

Nurse Intraoperative Report Functions All information is reviewed & completed Editing has been completed “Sign the report” function

Press to continue, 'A' to access Nurse Intraoperative Report functions, or '^' to exit: A VeHUPatient, One ( ) Case # MAY 1, 2004 Nurse Intraoperative Report Functions: 1. Edit report information 2. Print/View report from beginning 3. Sign the report Select number: 3//

Signed Nurse Intraoperative Report Moves into TIU files Viewable on the Surgery tab

Nurse Intraoperative Report Addenda Changes to information contained on the report require an electronically signed addendum Created from any of the data entry options within the Surgery package

Nurse Intraoperative Report Addenda Entering the data entry option –User is alerted that the report has been signed Snapshot of the current record is stored –In the background –Transparent to the user

>>> WARNING <<< Electronically signed reports are associated with this case. Editing of data that appear on electronically signed reports will require the creation of addenda to the signed reports. Nurse Intraoperative Report Addenda

Exiting the data entry option –Second snapshot is taken –Compared with the original Any changes create an addendum

VeHUPatient, One ( ) Case # – MAY 1,2004 An addendum to each of the following electronically signed document(s) is required: Nurse Intraoperative Report - Case # If you choose not to create an addendum, the original data will be restored to the modified fields appearing on the signed reports. Create addendum? YES//

Addendum to Nurse Intraoperative Report for Case # – MAY 1,2004 Patient: VeHUPatient, One ( ) The Count Verifier field was changed from VeHUNurse, One to VeHUNurse, Two Do you want to add a comment? YES// NO Enter your Current Signature Code: XXXXX SIGNATURE VERIFIED

Nurse Intraoperative Report Addenda The user elects not to sign the addendum –All changes made will be backed out –Restores the database to reflect what was originally signed on the report

MEDICAL RECORD NURSE INTRAOPERATIVE REPORT PAGE 1 Case # 001 Operating Room: OR1 Surgical Priority: ELECTIVE Patient in Hold: MAY 01, :00 Patient in OR: MAY 01, :30 Operation Begin: MAY 01, :45 Operation End: MAY 01, :30 Surgeon in OR: NOT ENTERED Patient Out OR: MAY 01, :40 Major Operations Performed: Primary: CHOLECYSTECTOMY Wound Classification: CLEAN Operation Disposition: PACU (RECOVERY ROOM) Discharged Via: STRETCHER Surgeon: VeHUProvider, One First Assist: VeHUNurse, One Attend Surg: VeHUProvider, Two Second Assist: N/A Anesthetist: VeHUProvider, Three Assistant Anesth: VeHUNurse, Two OR Support Personnel: Scrubbed Circulating VeHUNurse, Three VeHUNurse, Four Valid Consent/ID Band Confirmed By:VeHUNurse, Four Skin Prep By: VeHUNurse, Three Skin Prep Agent: N/A Preop Shave By: VeHUNurse, Three Surgery Position(s): SUPINE Placed: N/A Restraints and Position Aids: SAFETY STRAP Applied By: N/A Electrocautery Unit: 7299 ESU Coagulation Range: N/A ESU Cutting Range: N/A Electroground Position(s): N/A Tubes and Drains: PENROSE, CYSTIC DUCT STUMP EXTERIORIZED TO LATERAL ABDOMINAL WALL Medications: DIAZEPAM 5MG/ML 2ML SYRINGE Time Administered: MAY 01, :55 Route: INTRAVENOUS Dosage: 10mg Ordered By: VeHUProvider, One Admin By: VeHUNurse, Four Comments: N/A Irrigation Solution(s): NORMAL SALINE Time Used: MAY 01, :05 Amount: 1000 Provider: VeHUProvider, One Sponge Count: YES Sharps Count: YES Instrument Count: YES Counter: VeHUNurse, Four Counts Verified By: VeHUNurse, Three Dressing: TELFA, OP SITE Blood Loss: 200 ml Urine Output: 1000 ml Postoperative Mood: RELAXED Postoperative Consciousness: RESTING Postoperative Skin Integrity: INTACT Nursing Care Comments: NO COMMENTS ENTERED

. Sponge Count: YES Sharps Count: YES Instrument Count: YES Counter: VeHUNurse, Four Counts Verified By: VeHUNurse, Three Dressing: TELFA, OP SITE Blood Loss: 200 ml Urine Output: 1000 ml Postoperative Mood: RELAXED Postoperative Consciousness: RESTING Postoperative Skin Integrity: INTACT Nursing Care Comments: NO COMMENTS ENTERED Signed by: es/ VeHUNurse, Four VeHUNurse, Four 05/08/01 14:59 05/21/ :37 ADDENDUM The Count Verifier field was changed from VeHUNurse, One to VeHUNurse, Two Signed by: es/ VeHUNurse, Four VeHUNurse, Four 05/21/ :37

Nurse Intraoperative Report Addenda Concurrent Cases

Documentation including User, Technical Manuals and Release Notes can be found on the Electronic Signature for Operative Reports VDL Web page. Additional References

Surgery Electronic Signature for Operative Reports Scott Ridings

Overview TIU ASU Surgery Tab within CPRS GUI 508 Compliance Features

TIU Text Integrated Utilities

TIU This is where Reports, Discharge Summaries and Progress Notes are stored and maintained.

What role does TIU play in the Electronic Signature for Operative Reports? Answer: This is where all Operative Reports will be stored. Specifically File 8925.

What role does the Clinical Applications Coordinator and Surgery ADPAC have with the Installation of the TIU portion of the Electronic Signature for Operative Reports?

ANSWER: You will need to work together as a TEAM to complete the Pre- Installation Worksheet.

Why is this so Critical? Because your decisions reflect the policies and practices of your hospital.

TIU*1.0*112

Surgical Reports as a Coordinate Class.

CLINICAL DOCUMENTS CL +ADDENDUM DC +DISCHARGE SUMMARY CL +PROGRESS NOTES CL - SURGICAL REPORTS CL OPERATION REPORTS DC OPERATION REPORT TL NURSE INTRAOPERATIVE REPORTS DC NURSE INTRAOPERATIVE REPORT TL ANESTHESIA REPORTS DC ANESTHESIA REPORT TL PROCEDURE REPORT (NON-O.R.) DC PROCEDURE REPORT TL Clinical Documents

The Surgical Reports will be activated upon Installation The reports won’t be usable until implementation of SR*3.0*100

What functionality will be used to control and restrict access to the Surgery Documents within TIU and CPRS ? Answer: Authorization Subscription Utility (ASU)

No TIU Business Rules will be exported with TIU*1.0*112. Sites will need to devise their own policies.

Surgery Tab CPRS GUI

CPRS GUI A Surgery tab was developed to support the display and management of Surgery report documents. The layout and functionality of the tab was modeled after the Consults tab.

CPRS GUI The Surgery tab can be suppressed for those sites not using the package. Parameter: ORWOR SHOW SURGERY TAB This parameter can be set at the following levels… User, Service, Division, System and Package

CPRS GUI Surgery Tab All Surgery documents will display from this tab.

Functionality will provide the ability to: Display Print Edit Electronically Sign Unsigned Operation and Procedure (Non-OR) Reports

Functionality will provide the ability to: Display Print Signed/Completed Operation and Procedure (Non-OR) Reports

Functionality will provide the ability to: Create Display Print Edit Electronically Sign Addenda for Signed/Completed Operation and Procedure (Non-OR) Reports

Functionality will provide the ability to: Display Print Nurse Intraoperative and Anesthesia Reports

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508 Compliance feature “N” and “O” on folders

CPRS GUI Version GUI Version 23 is compatible with the New Electronic Signature for Operative Reports functionality

SR*3.0*128 & TIU*1.0*187 Developed to address problems with patches SR*3.0*100 and TIU*1.0*112 SR*3*128 is released TIU*1*112 is in the testing phase and should be released shortly

The Installation Guide Worksheet

FAQs We’re a Cache site and during installation I’m receiving an error 61+1^DIU0 –You will need to change the protection on the global. This is done differently on Cache –S X=$ZU(68,28,0) before installation –Continue with installation How far back should I go to enter a date for electronically signing converted reports? –Recommendation is date of installation or you will need to re- upload previously uploaded documents

FAQs cont. Can I add addenda to historical cases (converted, but not e/s)? –Yes, they will need to be e/s What is the approach for direct entry, is it different than uploading? –Once the stub is created in TIU, after TIME PAT OUT Of OR is entered, the surgeon can find the stub in TIU and enter the text operation report directly into CPRS

FAQs Will I be able to get the Operative Reports in Health Summary and RDV? –Patch GMTS*2.7*57 will enable access to these reports

Questions ?