1. Surgery Quality and Workflow Manager
Preop Documentation
Same Day Surgery and Holding Area

2. Learning Objectives
After instruction, students will be able to complete the following tasks:
Access and navigate SQWM Documentation module through the SQWM Documentation icon.
Access and Navigate OR Census and Pending Work Census
Access and Complete Scripts
Document Forms
Additional Step when Signing V-forms
Document Patient Vitals
Access and navigate Periop Nursing Documentation through the Periop Nursing Documentation icon for documenting Patient In Facility
READ and DISCUSS Learning Objectives.
TRANSITION: Let’s take a look at where you document your Same Day Surgery and Preop Holding nursing care.

3. SQWM Documentation Icon
DISCUSS:
Selecting the SQWM Documentation icon takes you to the login screen for the Centricity Perioperative Anesthesia (CPA) application, which contains the v- forms and scripts for all perioperative care events except intraoperative.
TRANSITION: When you log into SQWM Documentation for Preop, the initial screen defaults to the OR Census.

4. OR Census Overview DISCUSS:
When users select OR Census, the patients assigned to them for the current day populate automatically.
Other search criteria, such as date, name, etc. can be added. You can enter a date range, or if looking for today’s patients only, leave it at the default of the current date. To search for a specific patient, enter the last name in the Last Name field and click Search.
You can also search by Social Security Number, or use the Quick Search option, which uses the first initial of the patient's last name and the final 4 of the Social Security Number. The Search functionality is a smart search and narrows options as you type.
Other search options include specific personnel, such as attending or resident, as well as case number or OR room number.
Column headings include Name, OR Scheduled, Scheduled Time, SSN, DOB, Anesthesia Attending, Procedure, CRNA, Resident, Preop Eval v-form, Surgeon, Case Number, PAT Concerns and Clinic. You can sort the columns by double clicking the column header.
TRANSITION: Let’s look at documentation options for the OR Census.

5. OR Census Menu Options DISCUSS:
When you click on the patient that you wish to document on, a menu of options displays.
The menu options depend on the role you are assigned.
The ones that we discuss today include: Surgery Verification Call, PREOP/PACU RECORD and PostOp Phone Call.
TRANSITION: The other census option that you have access to is the Pending Work Census.

6. Pending Work Census Options
EXPLAIN:
Any unsigned v-forms display on the Pending Work Census. The Worklist column indicates whether it is an unlocked v-form, procedure, etc. The patient’s name displays in the Name column. The last 4 of Social Security Number (SSN), Requisition Number, Date of Service and the Worklist Details display in the remaining columns.
Click on the patient and the form opens. Complete the form and then sign and lock. The form drops off the Pending work Census.
TRANSITION: Let’s look at where you document the Preperioperative Care Event. It is the only care event, with the exception of Intraoperative, that is documented in Periop Nursing Documentation.

7. Access Surgery Verification Call
DISCUSS:
Surgery Verification Call and Preop Nursing Call are accessed from the OR Census. First, select and click on your patient and then select the call you are making.
Click on the desired documentation to begin charting.
TRANSITION: Surgery Verification Call and Preop Nursing Call are v-forms that are completed in the Preperioperative Care Event.

8. Surgery Verification Call
DISCUSS:
The Surgery Verification Call is used by either a clerk or nurse to verify that the patient knows the correct time to arrive for surgery, has appropriate transportation arranged, where they are staying the night before surgery and who they spoke with and the number that they can be reached at. This can be done 1 to 2 days prior to surgery. The process for documenting in v-forms is the same.
TRANSITION: Let’s look at the Preop Assessment form for an example of how to document v-forms.

9. Enter Data in V-Forms EXPLAIN:
To enter data in the v-forms, certain script items, when selected, present a picklist of choices to select. Many times a default value displays, but this can be altered by selecting the field and a value from the list displayed.
Note: There are no arrows on the dropdown fields; however, a list of choices display when a field is selected.
Items for required documentation display in red font and have an asterisk next to the field. If these items are not documented when the user attempts to lock the case they are prompted to complete the remaining required items.

10. Signing V-Forms DISCUSS:
There is an additional step when you sign your documents. After you click “I, … have completed and reviewed this note.” The Password Required window displays.
Enter your password in the field, and then click OK.
TRANSITION:
Now, let’s take a look at how you can quickly tell which patients have had their surgery verification call completed.

11. Surgery Verification Call Completed
DISCUSS:
After you have completed and signed the Surgery Verification Call form, the line for that patient in OR Census turns green.
You can see which patients have had their Surgery Verification Call completed at a glance. The legend showing the color is at the bottom of the screen.
TRANSITION: There is one item that is documented in Periop Nursing Documentation.

12. Periop Nursing Documentation
DISCUSS:
Periop Nursing Documentation is where the patient arriving in the facility is documented.
This is the only documentation in Periop Nursing Documentation except for the Intraop Care Event.
Click on Periop Nursing Documentation.
Log into Centricity Perioperative Manager Clinical Documentation.
Select your patient from Case Selection.
TRANSITION: The Times module is where we will look next.

13. Times
EXPLAIN:
Select the Times icon and document the time the patient arrived in the facility. This triggers the change in Tracker and alerts staff by the color change that the patient has arrived in the facility.
A simple way to document the time as you work is to click the Current icon to enter the current time.
Some facilities are granting access to this module to auxiliary staff and they are doing this step at the time of check-in.
Please check with your supervisor for the policy at your facility.
TRANSITION: Next we will learn about scripts. We return to SQWM Documentation where everything else is documented for Preop.

14. Preop Nursing Documentation
EXPLAIN:
The Scripts are accessed by clicking PREOP/PACU Record.
TRANSITION: Let’s look at the different script options.

15. SQWM Documentation Script Choices
EXPLAIN:
The different care events are listed in tree format, usually with the Anesthesia option expanded. Click on the ( – ) beside Anesthesia to close that option and click on the ( + ) in front of the care event that you wish to document.
PREOP opens to one choice (Case Cancellation is not an option).
Choose the desired script by clicking it.
TRANSITION: Let’s look at the information that displays in the scripts.

16. Scripts in SQWM Documentation
DISCUSS:
When the script opens, you see a banner with the patient information and the clock showing the amount of time since you clicked PreOp start, designating the beginning of their time in that care event.
Just below this is a standard toolbar for all the scripts. The format of the scripts and the way you document in them are the same no matter which care event you are in.
TRANSITION: We will look at the script toolbar next.

17. Script Toolbar DISCUSS: This is the standard toolbar:
Scripts returns you to the primary script after selecting additional information to document from toolbar.
Find (magnifying glass icon) in Menu allows you to search for additional documentation options. Select Find and the search field opens. Options display under the banner as search is typed.
Other in Menu allows you to enter comment.
Time can be adjusted as in Script documentation.
Meds is where you find the medications to document. Select the desired medication and then in the window that displays document the amount, route and time.
Infusion is where you find your drips to document, aminophylline, dopamine for example.
Fluids is where you document any IV fluids
Output is where you document any output.
Blood is where you document any blood products given.
Sites is where you document IV starts.
Select Mark from menu to place a timestamp for critical event documentation if needed.
Select Preop Start/Stop from menu to document beginning/end of preop care event.
Alerts allows you to name, set and edit a timer.
Select Patient Information (Pat Info icon) to add information to Patient Manager. Information includes ht, wt, ASA Status, Procedure and Allergies.
Select Chart from menu to see same menu options as when clicking on patient in OR Census.
Edit is not active at this time.
Select Sign In (Sign-In and Sign-Out icon) from menu, and then click Search for additional staff, break and relief staff to log in.
Select Logout from menu to lock workstation or exit module.
Close returns you to OR Census.
TRANSITION: Next, we add additional patient information.

18. Adding Patient Information
EXPLAIN:
You can add additional information in Patient Manager so that it shows in the banner.
Height and weight can be added here either in metric or English.
ASA can be added if known at this point.
Allergies pull over from CPRS and additions and changes must be done there. The additions then flow to SQWM.
TRANSITION: Nursing staff must sign in to their script.

19. Signing In
DISCUSS:
Nursing staff must sign in for their care event. Click Sign In in the toolbar.
You can either enter your last name, choose your role, and then click Search, or you can choose the appropriate role, then choose the name from the dropdown menu.
Then click on your name in the grid to highlight it, and click Sign In. You are now logged into the case.
TRANSITION: Next we will learn how to document in scripts.

20. Editing in Scripts EXPLAIN:
To document in the scripts you click on the desired documentation.
You can edit the documentation, for example to adjust the time.
Click the … first, make the adjustments, then click on desired documentation.
After you click on the desired documentation, another window may display for further details.
These windows may contain fields to type in text or dropdown menus to choose from.
After the documentation is completed, it then moves to the Event History window at the bottom right of the screen.
TRANSITION: Let’s look at Event History next.

21. Event History in Scripts
DISCUSS:
The Event History shows at the bottom right of the screen. Everything that has been documented in this care event’s script displays here.
TRANSITION: Let’s learn how to edit in Event History.

22. Editing Event History in Scripts
DISCUSS:
You can still edit or delete the documentation even after it is in Event History. Click in the Event History window.
The Notes/Events During Case window displays.
You can edit or delete documentation just as you did in the script. Click on … . Click on the desired edit.
TRANSITION: Next let’s look at additional documentation options.

23. Additional Documentation Toolbar
DISCUSS:
Additional scripts are available to use for documenting in the toolbar.
Select your desired category for additional documentation from the action menu. Choices include: Meds, Infusion, Fluids, Output, Blood, and Sites.
Banner changes to name of additional documentation chosen with Search field to right of name. Selections for this script change as search is typed.
Documentation is same as in PreOp script.
Other in Menu allows you to enter comment.
Time can be adjusted as in Script documentation.
Find (magnifying glass icon) in Menu allows you to search for additional documentation options. Select Find and the search field opens. Options display under the banner as search is typed.
Select Mark from menu to place a timestamp for critical event documentation if needed.
Select Preop Stop from menu to document end of preop care event.
Select Patient Information (Pat Info icon) to add information to Patient Manager. Information includes ht, wt, ASA Status, Procedure and Allergies.
Select Chart from menu to see same menu options as when clicking on patient in OR Census.
Select Sign In (Sign-In and Sign-Out icon) from menu, and then click Search for additional staff, break and relief staff to log in.
Select Logout from menu to lock workstation or exit module.
TRANSITION: Let’s learn how to document Vital Signs.

24. Document Patient Vitals
EXPLAIN:
To document vital signs, you click the Mo icon on the right side of the screen. The vital sign grid displays.
Click in the appropriate grid. Window displays for you to document the vital sign value. Enter the value in the value field and either click Record & Next to enter more values or click Record and then Close.
New columns display by default every 5 minutes. This works just like your flowsheet in Periop Nursing Documentation.
The columns that do not have any values in them do not display on your record.
TRANSITION: Next, we learn how to edit vital signs.

25. Editing Vital Signs DISCUSS:
If a value is incorrect, you can correct it. First, click on the grid with that value, and then click Mark as Artifact.
Next, enter the correct value, and click Record.
Then click Close.

26. Preop Documentation DISCUSS:
Choose the PreOp script for documenting the preop holding care event.

27. Forms in SQWM Documentation
DISCUSS:
Some scripts have forms included as part of the documentation. Click on the form and the v-form displays. Continue to document as you normally do in v- forms.

28. Script Practice
Patient A is having a laparoscopic left hernia repair with mesh and has just had his IV started in the Preop area. Document the IV start.
ASSIST: Move around room providing assistance as necessary.
ASK: What questions do you have about the new places to document your care event? How do you access it?
INSTRUCT: Provide directions to complete the exercise.
Log into SQWM Documentation.
Locate the patient and click on them to bring up menu.
Click Preop/PACU Record.
Click Preop script
Click on Peripheral IV.
Document in window that displays.
TRANSITION: Lab results can be accessed from CPRS while in SQWM.

29. Accessing Labs DISCUSS:
There is a quick and easy way to view labs from within SQWM. Simply click Labs from the menu that displays when you click on your patient.
TRANSITION: Let’s learn next what can be seen on the Labs page and the different parameters you can use to limit your results.

30. Labs
DISCUSSION:
The different parameters available when you view Labs include Groups, Priority, Time Span, Time Compression and Microbiology.
Groups: Use the dropdown menu under Groups to change the type of lab that you are viewing.
Priority: Choose from All, Typical or Critical.
Time Span: When you view the labs, the time span defaults to three days. You can choose a different time span by clicking on the dropbox under Time Span. Your choices go from today to No Limit.
Time Compression: You can choose None, Day, or Week from the Time Compression dropdown menu.
If you wish to also see Microbiology, click the box underneath Microbiology. A checkmark displays and Microbiology is included in the labs.
There are also Defaults and Search buttons
Defaults: Click the Defaults icon to return the choices to default, which are Default, Typical, Three Days, None and no Microbiology.
Search: Allows you to search for a specific result.
TRANSITION: Let’s look next at Tracker.

31. Track Surgery EXPLAIN:
The Tracker Module allows users to better manage resources during the day of surgery. Tracker shows where patients are in their surgical experience. Time updates are all real time and feed in from the clinical documentation packages for more accurate logging.

32. Case Label
EXPLAIN:
After selecting a date, the cases scheduled for that date display in Case Grid View. In Management view, the Case Label displays the surgeon, patient, procedure and age of the patient. To view additional information on each case, right click the case label. The options to Show Patient Drill Down and View Case Label Values display.
Case Labels are color coded based on their status. The status designations include Add On, Emergency, Scheduled, In Facility, Holding/Preop, In OR , Incision (only displays in Management View), Surgery Started (only displays in Ancillary and Family views), Surgery Ended, in PACU and Discharge. As the case is logged in the Clinical Documentation module, the color of the case changes in all views of the Tracker module.
The case label boundaries are driven by the times that the patient is actually in the operating room as entered in the clinical documentation module.
NOTE: If the case is too short for all of the information normally on the case label to be easily visible, hover your mouse over the ellipses ( ... ) to view the option to display the rest of the information

33. Case Label – Show Patient Drill Down
EXPLAIN:
If you choose the Show Patient Drill Down option, the Patient and Case Details window displays, which includes Scheduled Start Date/Time, Scheduled Duration, Service Area, Patient Demographics, Case Information, Allergies, Case Comments and Tracker Times.

34. Tracker Icons Operative Consent Staff Note Complete H&P Complete
Bed Available
Isolation Status
Blood Consent
IV in Place
NPO
Labs/Tests
EKG
Site Physically Marked
Staff Surgeon Visit Complete
DISCUSS:
This is a close-up of additional Tracker icons that are available to help users know the status of tasks needed to for a patient waiting for surgery.
Icons display at the top of the label to indicate items that have been completed and/or are outstanding.
Hover over the icons to display the icon description and if the item is complete or incomplete.

35. Review We have covered the following topics:
Access and navigate SQWM Documentation module through the SQWM Documentation icon.
Access and Navigate OR Census and Pending Work Census
Access and Complete Scripts
Document Forms
Additional Step when Signing V-forms
Document Patient Vitals
Access and navigate Periop Nursing Documentation through the Periop Nursing Documentation icon for documenting Patient In Facility
REVIEW:
In this section, we learned how to log in, access and navigate in SQWM Documentation. We discussed how to search for and select patients, and that we document all care events except Intraoperative in SQWM Documentation.
We do, however, still document the time the patient arrived in the facility on the Times screen in the Preperioperative Care Event.
We also learned about scripts, how to access scripts for the different care events, how to document in them and how to edit them.
We reviewed how to document in v-forms and the new step when signing and locking v-forms. We learned how to document vital signs for sites that are using device capture and how to when facilities are not.
What questions do you have about any of those processes?
ASK:
What are the differences in where you chart your care events? Where would you click to access those areas?

36. SDS/ Preop Real World Scenario
Patient C presents for left shoulder arthroscopy with subacromial decompression and is going to have an infraclavicular brachial plexus block with continuous catheter placement in holding. You gave 3 mg of Versed for the block. Document your care for this patient.
ASSIST: Move around room providing assistance as necessary.
ASK: What questions do you have about the new places to document your care event? How do you access it?
INSTRUCT: Provide directions to complete the exercise.
Log into SQWM Documentation.
Locate the patient and click on them to bring up menu.
Click Preop/PACU Record.
Click Preop script
Click on Peripheral IV.
Document in window that displays.
Click Meds from toolbar and document Versed.

37. Help Desk and References
Two methods of entering a service request
eService - low priority ticket
Phone – critical, high, medium, low priorities
Press 4 for Surgery Quality and Workflow Management, then
Press 4 to speak to technical support
SQWM Training SharePoint Site:
EXPLAIN
There are two methods to of entering a service request, eService and by phone.
Additional training information can be found at the SQWM Training SharePoint Site.

38. Course Evaluation EXPLAIN:
Your input and feedback is greatly appreciated.
Direct students to End of Course Evaluation location.