1. Joy Pasternock EVS, HDS Scott Ridings EVS, HDS
Electronic Signature for Operative Reports
Joy Pasternock EVS, HDS
Scott Ridings EVS, HDS
This presentation has been designed to provide general information about the Electronic Signature for Operative Reports project and in some areas specific details.

2. Objectives Provide an Overview Review Installation & Site Parameters
Review Signing Operative Reports
This presentation has been divided into three sections.
The Overview will provide general information about the Electronic Signature for Operative Report enhancements.
The section titled “Installation and Site Parameters” provides information related to pre-installation setup, including site parameters and report conversions.
The final section, “Signing Operative Reports” provides detailed information on the new features created for electronically signing Operative reports.

3. Overview

4. Surgery Electronic Signature Enhancements
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.
This enhancement provides the ability to electronically sign operative reports contained within the VistA Surgery application.
It provides the ability to view these signed reports on a the Surgery Tab in CPRS, by storing them within the Text Integration Utilities (TIU) package. TIU also stores other document types such as Progress Notes & Discharge Summaries.

5. Reports Operation Report Nurse Intraoperative Report Anesthesia Report
Procedure Report (Non-O.R.)
The Electronic Signature for Operative Reports enhancement provides the ability to electronically sign four reports. These are the Operation Report, Nurse Intraoperative Report, Anesthesia Report, and Procedure Report (Non-O.R.), that are all stored in TIU as previously mentioned.

6. Operation and Procedure (Non-O.R.) Reports
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
The dictated Operation Report and Procedure Report Summaries are signed using the Surgery Tab in CPRS or Text Integration Utilities functions.
By using TIU features, all document management for these two reports can be accomplished with existing TIU functions. Scott will show examples later in the presentation.
Cannot be signed using options within the Surgery Package.
The surgeon is legally responsible for signing the dictated operative summary of the operation report.

7. 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
The Nurse Intraoperative Report and Anesthesia Report are processed differently from the Operation Report. These are comprised primarily of information contained in specific fields entered through the Surgery package as opposed to a dictated summary.
These two reports can only be electronically signed using Surgery options.
They cannot be signed from the Surgery Tab.
Although they are viewable on the Surgery tab, they cannot be signed or edited there. All edits to these 2 reports must be done within the Surgery Package options.
The report is uploaded into the TIU software upon signature, making it viewable on the Surgery tab within CPRS.

8. 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
Addenda for these reports are also created solely within Surgery options.
By controlling the signature of the reports and any subsequent addenda through the VistA Surgery options, the information in the Surgery database and that which is stored on the electronically signed report remains the same. Whatever you see in TIU is a copy of the fields entered in the surgery package.
Every data entry option within the nationally released Surgery package has been updated to accommodate the automatic addendum feature.

9. Installation and Site Parameters

10. 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 Surgery patch that provides the Electronic Signature for Operative Reports enhancements is SR*3*100.
Prior to installing this patch, several setup issues need to be resolved.

11. Requirements Prior to Installation
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
The Surgery patch requires the TIU patch TIU*1*112.
Once the TIU patch is installed, then the document definitions can be defined using the TIU options. These document definitions are similar to those the CAC sets up at your site for Progress Note, Discharge Summaries, and other Clinical Documents. Scott will go into further detail later in the presentation as he describes the installation of the TIU patch.

12. 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
A worksheet has been provided as part of the Installation Guide for the surgery e/s enhancements. It provides information regarding parameter settings and report conversions.
The worksheet should be completed by the Surgery Application Coordinator, with input from the Clinical Application Coordinator and other key Surgery staff.
Once completed, this worksheet will be provided to the person responsible for installing the patch.
It will be reviewed in detail upon completion of this presentation. This patch should not be installed without a completed worksheet.

13. 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
Determine if the Anesthesia Report is used at you Medical Center.
A new parameter ‘Anesthesia Report In Use’ has been added to determine if the Anesthesia Report within the Surgery package is used at your medical center.
Installer will be prompted to answer the prompt upon installation
Can be changed after installation using the Surgery Package Management Menu
This parameter will default to “NO” since most facilities do not utilize this feature of the Surgery package. It can be changed to “YES” during installation or changed after installation as previously mentioned.

14. 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.
Read this slide.
This information is found the SR*3.0*100 Installation Guide.

15. 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
During installation of the Surgery patch, the installer will be prompted to answer a series of questions regarding conversion of reports.
Allows the identification of existing cases that should be signed using the new software.
The software provides tools for making existing cases viewable through CPRS, even though they will not be electronically signed.
3. The Installation process will also convert any of the Operation Reports created using the Class III software developed by the Boston VA Medical Center.

16. 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
During installation, you can identify existing Surgery cases that should have reports electronically signed using the new features provided by the Electronic Signature for Operative Reports enhancement.
Surgical cases that are recent may not have transcribed Operation Reports yet. For these cases, it may be preferable to have these reports included for electronic signature using the new features included in this enhancement. This would provide surgeons with a single process for finalizing reports in progress that are not already signed.
The installer will be asked to enter a beginning date. Stub entries for the Operation Report will be created in TIU for all cases created on or after this date. The stub appears in CPRS folder that does not contain any surgical reports until completed. Hovering over the folder displays the operation date, surgical procedure, author/surgeon, and surgical case #. Once transcribed and uploaded into TIU, the Surgeon will be notified to sign the Operative Summary.

17. 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
All reports for all cases including the Operation Report, Nurse Intra op Report, non- or procedure report and if your site is utilizing the anesthesia report with an Operation Date on or after the date entered during installation will be included.
If a case already has an uploaded surgeon’s dictation or
A signed paper copy of the Operation Report
All associated operative reports will require electronic signature

18. Converting Reports
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.
This is an example of the question asked during installation of the Surgery patch.
The installer will be asked to enter a date.
Stub entries for the Operation Report will be created in TIU for all cases created on or after this date. Stub entries appear to the users as a folder within the tree view on the surgery tab. The folder does not contain any surgical reports until completed. Once transcribed and uploaded into TIU, the Surgeon will be notified to sign the Operation Report. The Circulating Nurse for each case will be alerted that the Nurse Intraoperative Report is ready for signature for each case also. If the site parameter “ANESTHESIA REPORT IN USE” is set to “YES”, the Principal Anesthetist will be notified to sign the Anesthesia Report.

19. Benefits Convenience to users Provides a practical medical record
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
There are many advantages to identifying reports for recent Surgery cases to be electronically signed.
Convenience to users – Ability to electronically sign reports vs. searching down paper copies
Provides a practical medical record by making it easier to locate reports and eliminates a dual system by having signed paper copies & electronic reports. Having electronic records provide more efficient medical record reviews and provides quick access to reports & documents for JCAHO visits.
Consistent method for signing & viewing reports similar to other TIU documents.

20. 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
Drawbacks to identifying existing reports for electronic signature is that the Surgeon, Nurse, or Anesthetist will need to electronically sign several reports that have already been signed on paper.
In addition to having to sign the reports that may have already been signed on paper, the dictation for Operation Reports and Procedure Reports (Non-OR) will have to be uploaded again, this time through TIU, (or the dictation in the SURGEON’S DICTATION field can be pasted into the stub document) before it can be signed because the stub document will be empty. (Alan Monsoky’s comment)
Staff Members may have left the facility making it difficult to get the documents signed. Often times the site defines a business rule to allow the COS or Service Chief to sign the documents.

21. 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
During Installation, each facility will determine whether they want to make the Nurse Intraoperative Report, Operation Report, Anesthesia Report, or Procedure Report (Non-O.R.) viewable for cases prior to installation of the Surgery Electronic Signature enhancements. These reports will not be electronically signed using the new software.
When selecting the beginning date for making existing cases viewable through CPRS, several factors should be considered. If you select a date that is too far in the past, the data stored for some surgical cases may not be complete and accurate. It is better to err on the side of caution when selecting this date. Reports for cases identified will be viewable by clinicians that have access to CPRS.
Once you determine which reports to make viewable and how far back to include cases, enter this information in the Installation Guide worksheet. The installer will need to know this information when installing the patch.

22. 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// <Enter>
Do you want to move the Procedure(Non-O.R.)Reports? NO// <Enter>
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
This example shows the series of questions asked during installation.
The starting date in this example is 1/195.
If no date is entered during installation, subsequent questions are not asked and no reports for existing cases will be made viewable within CPRS.
Review the screen capture.

23. New Surgery Package Management Menu Option
New Option in Surgery Software
Make Reports Viewable in CPRS
Allows moving additional reports for other date ranges after installation of the software
So now you’ve changed mind after installing, and now you want to convert some reports for other date ranges to view through CPRS.
A new option in Surgery Software, Make Reports Viewable in CPRS allows moving additional reports for other date ranges after installation of the software. The user would be prompted with same questions on the previous slide.

24. 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
You should exercise caution when running the option MAKE REPORTS VIEWABLE IN CPRS.
As indicated by the help text, this process is system intensive therefore make sure you have adequate disk space before running this option.
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.

25. Disclaimer
Shown when displaying reports for existing cases that have not been electronically signed
Alerts the reader that the information was not electronically signed
When displaying reports for existing cases that have not been electronically signed, a disclaimer will be shown. This disclaimer alerts the reader to the fact that the information was not electronically signed.

26. 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.”
The disclaimer reads:
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.

27. 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
Many sites have been using the electronic signature functions created by the Boston VA Medical Center.
Reports created using the Boston software will be automatically converted during the installation of the Surgery patch
Once converted, the Operation Reports created with the Boston software will be viewable on the Surgery tab within CPRS. They will no longer be viewable on the Progress Notes tab, you will only be able to view these on the Surgery Tab.

28. Electronically Signing Operative Reports
The next section of the presentation provides a general understanding of the processes used to electronically sign the various operative reports.

29. 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
There are two distinct processes for signing operative reports.
The process for signing the Operation Report and Procedure Report (Non-O.R.) are similar.
The process for signing the Nurse and Anesthesia Report follows a different path and is done via the VistA Surgery Package. The different processes will be clarified in the slides to come.

30. 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

31. Operation Report TIME PAT OUT OR Stub
Time patient leaves operating room
A stub entry for the Operation Report is created within the TIU package
Stub
When the time the patient leaves the operating room is entered, a stub entry for the Operation Report is created within the TIU package. The document has an “Untranscribed” Status at this time.
The stub displays in CPRS as a folder. Hovering over the folder displays the date of operation, procedure performed, surgeon/author, & Case #. The folder doesn’t contain any surgical reports until they are completed.

32. 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
When the dictated Operation Report is transcribed and uploaded into TIU, the TIU parameters settings will determine when the view alert is sent to the Surgeon/Attending.
Will the documents require release
Will they require MAS verification
What are the signature requirements
When is the co-signer alerted
I will go into further detail regarding these parameters in the slides to come.
After these parameter setting are evaluated the alert is sent signaling the Operation Report is ready for signature.

33. 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

34. 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

35. 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

36. 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

37. 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
By selecting the alert, the software takes the Surgeon to the Surgery tab and automatically displays the report for signature.
The following slide display shows the unsigned Operation Report. The Surgeon will only be signing the operation report summary that is usually dictated but can also be entered directly.

38. This is an example of an unsigned Operation Report within the Surgery Tab. Notice the tree view to left under All Surgery Cases looks very similar to Progress Notes as well as the text display to the right.

39. Operation Report After signature
Operation Report viewable on the Surgery tab to other users
Once signed, the Operation Report will be viewable on the Surgery Tab to other users.

40. 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
The process for electronically signing the Nurse Intraoperative Report and Anesthesia Report is different than signing the Operation Report. The difference is that these reports are comprised of specific data elements entered through the Surgery software, and do not include a dictated summary like the Operation Report.
The Nurse Intraoperative Report and Anesthesia Report can only be signed using VISTA Surgery functions.
This presentation will use the Nurse Intraoperative Report in its examples.

41. 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
When the time that the patient leaves the Operating Room is entered in the TIME PAT OUT OR field, the Circulating Nurse receives an electronic alert notifying her/him that the Nurse Intraoperative Report is ready for signature.
By acting on the alert, the nurse is taken directly to the Nurse Intraoperative Report option within the Surgery package. From this option, the report can be displayed, printed, edited, or electronically signed.

42. 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
There are some required fields within the Nurse Intraoperative Report that must have data entered in order for the nurse to sign the report.
They include the times that patient enters and leaves the operating room. TIME PAT IN OR & TIME PAT OUT OR
If the COUNTS VERIFIED BY field has been entered, then other count related fields must also be entered. These include the SPONGE COUNT CORRECT (Y/N), SHARPS COUNT CORRECT (Y/N), INSTRUMENT COUNT CORRECT (Y/N), SPONGE, SHARPS, & INST COUNTER.
Fields for ensuring correct surgery are also required, and include MARKED SITE CONFIRMED, PREOPERATIVE IMAGING CONFIRMED, and TIME OUT VERIFIED.

43. VeHUPatient, One ( )
MEDICAL RECORD NURSE INTRAOPERATIVE REPORT - CASE # PAGE 1
Operating Room: WX OR 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 <return> to continue, 'A' to access Nurse Intraoperative Report
functions, or '^' to exit: A
This is an example of a reformatted Nurse Intraoperative Report. When selecting the Nurse Intraoperative Report option, this first page is displayed from entries within the data element fields in the surgery package, followed by the prompt “Press <return> to continue, 'A' to access Nurse Intraoperative Report functions, or '^' to exit:”

44. Nurse Intraoperative Report Functions
All information is reviewed & completed
Editing has been completed
“Sign the report” function
Once all information on the report has been reviewed and completed, the Nurse selects the “Sign the report” function. When the report is electronically signed, it is moved into the TIU files as a signed document, making it viewable on the Surgery tab.
Using the Nurse Intraoperative Report functions, you can edit, print, or sign the report.

45. VeHUPatient, One (000-00-0001) Case #000001 - MAY 1, 2004
Press <return> 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// <Enter>
This is a screen capture that is displayed to the nurse
By acting on the alert, the nurse is taken directly to the Nurse Intraoperative Report option within the Surgery package. From this option, the report can be displayed, printed, edited, or electronically signed.
If there was information to be edited, #1 would be selected. This allows you to enter any field contained on the report from a single data entry option.
If you wanted to print or view the report, then #2 would be selected.
This example displays the Nurse Intraoperative Report functions. To sign the report, the nurse selects number 3, “Sign the report”.

46. Signed Nurse Intraoperative Report
Moves into TIU files
Viewable on the Surgery tab
When the report is electronically signed, it is moved into the TIU files as a signed document, making it viewable on the Surgery tab.

47. 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
Once signed, any changes to information contained on the report will require an electronically signed addendum. Edits are made from the data entry options within the Surgery package.
Edits to a signed document will automatically create an addendum requiring e/s. These addendums will be displayed with the original TIU as an addendum, similar to the way they display in Progress Notes presently.

48. 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
Upon entering the data entry option, the user will be alerted that the report has been signed.
In the background, transparent to the user, a snapshot of the current record is stored.

49. Nurse Intraoperative Report Addenda
>>> 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.
This is the warning displayed when selecting a data entry option if the case has signed reports.
Read the capture

50. Nurse Intraoperative Report Addenda
Exiting the data entry option
Second snapshot is taken
Compared with the original
Any changes create an addendum
Upon exiting the option after editing, a second snapshot is taken and compared with the original.
If any changes have been made, an automatic addendum will be created.

51. VeHUPatient, One (000-00-0001) Case #000001 – 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// <Enter>
This example shows the series of displays and questions asked when editing a field contained on a signed report.
In this example, the COUNT VERIFIED BY field was changed using one of the Surgery data entry options. Upon exiting the option, this information is displayed.
Answering no to “Create addendum” will not save any edits and the document is restored back to it’s original state without the addendum

52. Addendum to Nurse Intraoperative Report for Case #000001 – 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
The software displays the information that will be contained on the addendum. You can add other information in a comment if necessary. The date and time of change will be stored when the addendum is created. You do not need to add this in the comment.
Entering your electronic signature code will sign the addendum and store it with the report in TIU.

53. 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
If the user elects not to sign the addendum, all of the changes made will be backed out, restoring the database to reflect what was originally signed on the report.
The user must sign the addendum immediately in order for the changes to be made and an addendum created.

54. MEDICAL RECORD NURSE INTRAOPERATIVE REPORT PAGE 1
Case # 001
Operating Room: OR1 Surgical Priority: ELECTIVE
Patient in Hold: MAY 01, : 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:
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: 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
This is an example of an unsigned Nurse Intraoperative Report. The next slide will display an example of the last page of a signed report, including a signed addendum.

55. .
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/ : ADDENDUM
The Count Verifier field was changed
from VeHUNurse, One
to VeHUNurse, Two
VeHUNurse, Four 05/21/ :37
At the end of the report, the electronic signature information is displayed. Since an addendum has been created for this report, it appears after the original signature.

56. Nurse Intraoperative Report Addenda
Concurrent Cases
Actually, the software has been designed to work with concurrent cases. Each report will require a separate signed addendum.

57. Additional References
Documentation including User, Technical Manuals and Release Notes can be found on the Electronic Signature for Operative Reports VDL Web page.
Additional information about the project can be found at several locations. A copy of this presentation will be available on the VEHU web site.

58. Surgery Electronic Signature for Operative Reports
Scott Ridings

59. Overview TIU ASU Surgery Tab within CPRS GUI 508 Compliance Features
Welcome. This presentation will provide a basic look into the setup required within TIU for The Electronic Signature for Operative Reports. The Overview will encompass significant information in regards to TIU, ASU, the Surgery Tab and 508compliance features. This presentation will conclude with the review of the Pre-Installation Worksheet.

60. TIU Text Integrated Utilities
Let’s get a understanding of the function of the Text Integrated Utilities. TIU provides a means of storing, maintaining and managing electronic documents.

61. TIU This is where Reports, Discharge Summaries and Progress Notes are stored and maintained.
Reports, Discharge Summaries and Progress Notes are the documents that reside within the TIU framework.

62. 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 will TIU play in the Electronic Signature for Operative Reports enhancements? The Operative Reports will be stored, maintained and managed through the functionality of TIU. More Specifically File 8925 is the file where these documents will reside.

63. 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?
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?

64. ANSWER: You will need to work together as a TEAM to complete the Pre-Installation Worksheet.
It is imperative that you work together to make the decisions as to how your parameters will be setup before the installation of this software. I cannot emphasize this enough. We will review the Pre-Installation Worksheet later on in this presentation.

65. Why is this so Critical? Because your decisions reflect the policies and practices of your hospital.
Make sure that you have addressed established Policies and Practices that have been defined by your hospital when responding to the parameter questions.

66. TIU*1.0*112
TIU patch 112, along with Surgery patch 100, provides the functionality of electronically signing reports and storing them within TIU. This patch was released on April 23 and has a 60 day compliance date. So, all sites should have it loaded by June 22nd 2004.
Let’s look at TIU*1.0*112

67. Surgical Reports as a Coordinate Class.
The Surgical reports will be imported as a Coordinate Class.
Let’s take a detailed look at the structure of Surgical Reports within the TIU Document Hierarchy.

68. Clinical Documents
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
Here you will see the actual Document Hierarchy of the Surgical Reports.
Surgical Reports will have its own class. Notice the – in front of surgical reports, indicated the expanded the class which now lists all the available reports.
The Operation, Nurse Intraoperative, Anesthesia and Procedure (Non-OR Reports will be Document Classes with associated Titles beneath them.
The reminder exchange utility is used when installing the TIU patch to populate the Surgical Reports Class and its subsequent Document Classes & Titles.

69. The Surgical Reports will be activated upon Installation The reports won’t be usable until implementation of SR*3.0*100
The new entries in the Document Definition file will be activated upon installation, but won’t be usable until implementation of Surgery patch SR*3.0*100 is complete.

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

71. No TIU Business Rules will be exported with TIU. 1. 112
No TIU Business Rules will be exported with TIU*1.0*112. Sites will need to devise their own policies.
Sites will need to devise their own Policies as to who will have access to these Documents.
There are a set of recommended business within the Surgery Installation Guide p.24.

72. Surgery Tab CPRS GUI
Since you have been given information as to how these reports are signed and where they can be found, I will take a few minutes and review the Surgery tab within the CPRS GUI Interface.

73. 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.
This tab was developed to support the display and management of the Surgery report documents.
The Surgery tab was modeled after the existing Consults tab.

74. 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
The Development staff has provided a means for suppressing the display of the Surgery tab within CPRS GUI through the use of parameter ORWOR SHOW SURGERY TAB.
The parameter can be set at the following levels. User, Service, Division, System and Package.

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

76. Unsigned Operation and Procedure (Non-OR) Reports
Functionality will provide the ability to:
Display
Print
Edit
Electronically Sign
This tab will provide the functionality to display, print, edit, and sign existing unsigned Operation Reports and Procedure Reports (Non-O.R.).

77. Signed/Completed Operation and Procedure (Non-OR) Reports
Functionality will provide the ability to:
Display
Print
For completed Operation and Procedure Reports (Non-O.R.), you will be able to display and print the report.

78. Addenda for Signed/Completed Operation and Procedure (Non-OR) Reports
Functionality will provide the ability to:
Create
Display
Print
Edit
Electronically Sign
Functionality will allow you to create, display, print, edit and electronically sign addenda associated with Operation and Procedure Reports (Non-O.R.).

79. Nurse Intraoperative and Anesthesia Reports
Functionality will provide the ability to:
Display
Print
The CPRS GUI Surgery tab will provide the functionality to display and print Nurse Intraoperative and Anesthesia reports, which should be signed within the Surgery package before they are stored in TIU.

80. Let’s review the Icon legend for the New Surgery tab.

81. I will review the icon for Case folder and the tree view that sites will be viewing.
I have resized the window so we are only viewing the surgery cases and reports in the tree view.
Will display a Tree View of Surgical Cases for the patient.

82. As you can see, if we click on the case folder it expands to display all reports associated with the case.

83. If we expand a report, we then may view the addendum associated with the individual report. (Slide # 84 on v11)

84. By clicking on the case, the Operation Report and associated addenda to the report are displayed. (slide #85 on v11)

85. Just as clicking on the Operation Report would display the Operation Report and addenda to this report, selecting the Anesthesia or Nurse Intraoperative Report will display the selected report and associated addenda. 85

86. 508 Compliance feature “N” and “O” on folders
Let’s review one of the 508 compliance features within the tree view for cases.

87. As part of the 508 compliance, folders have a designation of N or O
As part of the 508 compliance, folders have a designation of N or O. If you would please focus your attention inside the yellow folders you will see the N and O letters. The “N” simply identifies this case as an “Non-OR” case. The “O” subsequently identifies that this is an “Operative” case.
(Slide #88 on v11)

88. When expanding the Procedure Report (Non-O. R
When expanding the Procedure Report (Non-O.R.) within the tree view, you will notice that the “N” is still viewable from the folder. (slide #89 on v11)

89. CPRS GUI Version GUI Version 23 is compatible with the New Electronic Signature for Operative Reports functionality
I believe GUI v19 allowed this functionality to be used through CPRS GUI however, you should load the latest version of GUI which is presently GUI v23.
I would like to take this time to recognize the Development Staff that has made the new Surgery tab and Electronic Signature for Operative Reports a long-awaited reality.
Rich Vertigan- CPRS GUI Development
Alan Monosky-Surgery Development
Joel Russell & Andrew Bakke- TIU Development
Mike Montali- Project Manager
Bert Consentino – Provider Systems
Steve Musgrove – Provider Systems
Sami Alsahhar – Surgery Development
The Workgroup is a well diversified group that has provided the key information into the functionality of this project. They are a wonderful group of people and have represented the interests of the National VA Surgical Community with the highest degree of professionalism and dedication. I would also like to give a special thanks to the test sites that provided the testing and feedback for this project. We very much appreciate your time, your work and resources. Thanks again.

90. 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
SR*3.0*128 has been release and TIU*1.0*187 is under development to correct some problems noted with SR*3*100 and TIU*1*112. TIU*1.0*187 will correct problems with unattached addendums, concurrent case issues and reassignment problems for Operation Reports. SR*3*128 will remove the line **DRAFT COPY from historical surgical/non-OR cases that have been converted with a status of Completed but have no signature data. Additionally this patch will modify an input template to remove a few unneeded fields that should not appear on the Anesthesia Report. Both patches should be released shortly.

91. The Installation Guide Worksheet
As mentioned earlier, a worksheet is provided in the Installation Guide for the Surgery patch. We will briefly review it now.

92. There are three sections to this worksheet
There are three sections to this worksheet. Setting site parameters, Identifying Existing Reports to Be signed with the Electronic Signature Features and Making Reports for Pre-Existing Cases Viewable through CPRS.

93. This part of the worksheet provides a reference concerning your facilities decision pertaining to the use of the Anesthesia Report.

94. This sheet reviews information regarding the identification of cases to be signed with the Electronic Signature features. Your sites approved starting date for moving signed reports should be entered into the blank line for reference.

95. This is a page that provides important information related Making Reports for Pre-Existing Surgery Cases Viewable through CPRS. Please review this document carefully. Just as a clarification, these are reports that have been previously completed before the new functions were brought in by the surgery electronic signature enhancements project.

96. Here is an example of a completed Installation Worksheet for your review.

97. Here is the document that should be completed before installing SR. 3

98. FAQs
We’re a Cache site and during installation I’m receiving an error <PROTECT>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

99. 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

100. 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

101. Questions ?