1. Surgery Quality and Workflow Manager
Surgery Workflow

2. Learning Objectives
After instruction, students will be able to complete the following tasks:
Access and navigate Surgery Clinic Census, OR Census, Misc Census and Pending Work Census
Search for or select patients from various census lists
Schedule surgery or request approval for surgery
Access documentation options, document the surgical H&P, create a brief operative note, clinic note, procedure note, and dictated note report.
Thank participants for coming.
Introduce training team.
Ask participants to introduce themselves.
Ask participants for name, where they are from (if class participants are from various geographical areas), experience with the VA, and what they want to get out of the training.
Inform participants about schedule, breaks, lunch, as well as the location of bathrooms, exits, food, etc.
Set Classroom Expectations (cell phones off, starting on-time, minimize distractions).
Lead participants through material on their desks.
EXPLAIN:
During the instruction, you will be given the opportunity to practice each of the tasks listed as a learning objective. The purpose of today’s training is to provide an understanding of the functionality of the Surgery Quality and Workflow Manager tool, specifically the OR Census, Surgery Clinic Census, Misc Census, and Pending Work Census.
DISCUSS:
Learning Objectives.

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 documentation screens for both the anesthesia and surgery providers.
TRANSITION:
Let’s look at how to log in.

4. Log in
DEMONSTRATE:
To log in, click the SQWM Documentation icon. Enter your Login Name and Password. Click OK.
The Centricity Perioperative Anesthesia (CPA) login window allows the user to log into the CPA Application and change the password.
EXPLAIN:
The permissions granted are based on the role of the user. Some actions demonstrated may not be performed by all users. Role specific privileges are highlighted throughout the training.
NOTE:
As we walk through the examples and practice exercises, you will see what appears to be patient data. All screenshots and training exercises take place in a training database, and no actual personal patient data is used.
TRANSITION:
Next, let’s look at the Census options available on login.

5. Census Selection DISCUSS:
As we work in the different areas of the software, we will discuss several different censuses. A census is simply a list of patients or items needing attention. Different logins have a different census as the default, which is the list that opens automatically on log in. This is usually established by role.
The Census options for a surgeon or resident are OR Census, Surgery Clinic Census, Miscellaneous Census, and Pending Work Census.
The Surgery Clinic Census lists the patients scheduled for a consult in the surgery clinic.
OR Census lists patients scheduled for surgery on a particular day.
Miscellaneous Census, which is also called Waitlist Census, lists patients who are indicated for surgery. This is also where users can track medical readiness. Patients are placed on this census once they are indicated for surgery and remain there until the surgery is performed.
The Pending Work Census lists the unsigned notes or other items that require attention.
TRANSITION:
First, we discuss the Surgery Clinic Census.

6. Surgery Clinic Census EXPLAIN:
For residents and surgeons, the Surgery Clinic, is the default clinic and displays on login. Surgeons cannot manually add patients to this clinic. Patients display on the Surgery Clinic Census following a consult request.
TRANSITION: Let’s look at how to find patients in the Surgery Clinic.

7. Search Options EXPLAIN:
For residents and surgeons, the Surgery Clinic is often the default clinic, and it displays on login. Patients display on the Surgery Clinic census following a consult request.
The process to search for patients in the Surgery Clinic or the Misc Census is the same. First, select a clinic from the Unit dropdown, such as General Surgery, Orthopedics, etc.
A default unit for the user can also be designated for users in the Surgery Clinic Census and the Misc Census. Surgery and Misc Census have multi-select instead of a dropdown menu. You can select multiple units or use the multi-select option to select all units. However, if you use the Select All option, the system limits your results to the first 500.
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 set to the default of the current date. You can now search by Social Security Number, or use the Quick Search option. The quick search is the first initial of the patient's last name and the final 4 of the Social Security Number. In some areas, the Search functionality is a smart search and narrows options as you type. Other filters you can use include selecting Status, Surgeon, or PCP. The Status and Service fields also have multi-select options. Once the appropriate entries are made, click Search. The entries matching your search criteria display. Results columns can be sorted by double clicking the column header.
NOTE:
You must have a Unit selected before searching to get any results.
TRANSITION: Let’s look at some new toolbar icons and what they do.

8. Census Navigation and Toolbars
Surgery Clinic Census Toolbar
OR Census Toolbar
EXPLAIN:
Many of the Toolbar icons are the same for all the Census windows:
Back takes you back to the clinic you were in before or returns to the previous page.
Log Out allows the user to log out and enables someone to log in as a different user.
The New Case icon allows you to schedule a new case if you need to schedule multiple cases on the same patient.
Census displays the dropdown of the available Census options for the current user.
Approval is located on the Surgery Clinic Census and accesses the Approval queue for surgeons to approve or reject residents’ requests for surgery.
Export allows the user to export the Census to a CSV file.
Worklist displays a list of unlocked forms or follow up items pending or needing additional attention. This is the same as the Pending Work Census.
Monitor allows the user to remotely access monitors that are used in the OR.
Print when selected on the OR Census, prints the census content displayed.
Refresh provides a refresh or update of the most up-to-date data.
VistA Web provides access to the web-based CPRS notes for the patient.
TRANSITION: Let’s look at using the Export icon to export a list of your search results.

9. Export to CSV
EXPLAIN:
As seen on the previous slide, the Export icon is available on the toolbars for the OR Census, Surgery Clinic and Misc Census.
The system allows patients to be exported from a search. Users with the appropriate Security rights are able to export the information to a CSV file.
For example, you can do a search for a list of patients meeting a certain criteria, then you can export that list, and pull it into Excel. Uses for an exported list include creating a patient list for the day for the surgeon or clinic, or managing and scheduling patients for surgery.
Once you select the Export icon, a dialog box displays allowing you to save the file to CSV format.
TRANSITION: Let’s look at some of the options of the Surgery Clinic Census.

10. Surgical Clinic Documentation
EXPLAIN:
After you execute the search in the Surgery Clinic Census and the patient list displays, select a patient and click to display documentation options.
Select a documentation option, and then open the form. Icons are now available to access CPRS and Labs from within the Surgery Clinic Census.
Selecting Clinic/Procedure Note opens a page that displays folders containing various procedure note templates for selection..
A VASQIP Risk calculator, which is a morbidity and mortality calculator, allows the surgeon to analyze data and tell the patient the percentage of risk to determine if they want the surgery.
The Request for Surgery icon allows the surgeon to open a Request for Surgery form as well as enter a request in the Request Queue for the scheduler to schedule.
Clinic and Follow up Notes are available, and display according to the specialty of the surgeon. For example, Orthopedics Clinic Notes display for an Orthopedic surgeon.
Also available are Patient Preop and Discharge Instruction notes, as well as a form for the Preop Phone Interview.
A Dictated Note Report is available for the surgeon to attach to the dictated note.
TRANSITION: Let’s look at accessing Labs from within SQWM.

11. Lab Interface EXPLAIN:
The Labs icon on the Forms toolbar provides access to labs ordered for the patient. This screen is also available on the Documentation dropdown in OR Census, Surgery Clinic Census, Misc Census and VASQIP Census. Labs can be searched for by selecting groups, time frames, and priorities. Click Labs and the Labs module displays.
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 dropdown under Time Span. Your choices range 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 on the Defaults icon to return the choices to default, which are Default, Typical, Three Days, None and no Microbiology.
Search: Allows to search for a specific result.
TRANSITION: In addition to accessing Labs, you can also access previous SQWM notes.

12. Access CPRS from within SQWM
EXPLAIN:
After you execute a search and the patient list displays, select a patient and click to display documentation options, as seen on the previous slide.
Select the CPRS link to access a patient’s CPRS record.
TRANSITION: Next, let’s look at how to access forms.

13. Clinic Notes
EXPLAIN:
The form selection dialog box displays. The Date and Time defaults to the date and time the form is launched. This can be altered prior to opening the form.
There are several form versions presented in the dropdown for the surgeon or resident to document:
The Datacopy option is the default. It is recommended to leave this option checked so that information pre-populates or flows into the forms. This allows any information documented in the previous forms to flow into the current form if they are similar.
TRANSITION:
Let’s look at how to document using forms. First, we will look at the information contained in the form banner.

14. Patient Banner EXPLAIN:
The patient banner that displays at the top of the form contains important information on the selected patient so that it can be seen with higher visibility.
Information is populated from documentation within the form or from scheduled case information. The Refresh icon must be selected for documented information on the form to display on the banner after charting.
Information displayed can include: Name, Date of birth, Gender, MRN, Scheduled Procedure, and Allergies.
Additional banner information displays by clicking the red box at the far right of the banner.
The form header displays the form name, date and time when the form was initiated, and the name of the user who launched the form.
With the form for new consult, the top of the banner indicates who opened the form. If information has been entered by someone else, you see who and when.
TRANSITION: Let’s look at the Forms toolbar and what each icon does.

15. Forms Toolbar EXPLAIN:
The toolbar icons for the various forms include:
Back is used to return to the previous page displayed.
Logout is used to change users without exiting the application.
The Labs icon provides access to labs ordered for the patient.
Conversion is a conversion tool that can be used to convert between units of measure such as weight, temperatures and length.
Procedures launches the folders for the Procedure Note templates.
Census returns the user to the census from the current page.
WorkList displays a list of unlocked forms or follow up items pending or needing additional attention. This is the same as the Pending Work Census.
Risk Calc is a risk calculator available that calculates the risks from surgery for the patient.
Transmit transmits the form to CPRS.
Edit controls whether a form can be viewed or edited. If you have edit privileges, it defaults to Edit mode.
Print prints the form contents of the form displayed.
Refresh provides a refresh or update of the most up-to-date data.
The Expand icon opens all panels within the form displayed.
Collapse returns the panels to their closed positions.
New Form allows the user to select a new form to complete.
Click the down arrow at the end of the toolbar to display additional toolbar icons.
Add Variable allows you to add additional parameters to a form.
Open Form opens the form for editing.
Modify allows someone with edit privileges to modify data that was entered incorrectly.
Delete removes information if it was entered in the wrong place, for example.
TRANSITION: Next we will look at documenting the form itself.

16. Document Form EXPLAIN:
Once the form is chosen, the empty form displays with all the panels collapsed, ready to be opened and documented.
Forms may contain different information, but they all contain similar elements, which are described in the upcoming slides.
The T on the far right of the header is used to change the template to another related template. (Point out red box) For example, if the wrong form was selected inadvertently, the T can be selected and all documented information is saved and transferred to the new selected template.
This is not the same as the new form icon since it continues on the same form and does not open a new instance of the form.
TRANSITION:
Let’s look at accessing notes previously entered in SQWM.

17. Access Previous SQWM Notes
EXPLAIN:
Any notes previously entered in SQWM can be accessed by selecting the Open Form icon.
A dialog box displays with a list of any previously documented forms. Select the appropriate form to open and view previously documented information.
TRANSITION:
Let’s look at the different ways to enter information into the forms.

18. Enter Data in the Form EXPLAIN:
Each form is made up of panels. The panels group assessment information. The Patient Information panel reflects information that was captured through the scheduling process and automatically populates the form when launched. Any updates made to that information outside the form would not update a form that is already launched.
You can expand or collapse a panel by clicking the plus (+) or minus (-) sign. You can also use the expand and collapse icon in the toolbar.
The forms also allow you to select from a list of common data, shortening the amount of time you spend documenting and standardizing the documentation. To enter data using the lists, click the parameter to be assessed. The list of items for the parameter display. Select the appropriate item from the list. If the choice you want is not available, you can enter free text data.
Within Normal Limits (WNL) is configured for each panel where applicable. When selected, the WNL button charts the appropriate verbiage to indicate a normal assessment for that section. The data for an individual entry can be changed once WNL has been documented.
No Change (NC) displays next to the WNL button only when more than one form has been documented. The No Change feature is used to pull information from like forms. To document, select the + sign in front of the panel description to expose the objects available for charting. The objects may allow for a single selection of answers or multiple selections, date/time formatting or free text fields.
Some objects may group several related objects. The user may chart a portion or all components in the grouping. Other objects have a waterfall effect, and once the first selection is made subsequent details are requested.
TRANSITION: Let’s look at how to add new parameters to document in a form.

19. Add Variable
EXPLAIN:
The different forms available for documentation function in the same way, but the information documented may vary. When you want to document information not shown on the form, you can add a variable by clicking Add Variable on the toolbar.
Add Variable lets you add a space on the form for additional information. To add a variable, click Add Variable and select from the new parameter list for the information you want to document.
Click Close to hide the New Parameter List window.
TRANSITION: Let’s look at how to sign and complete the form.

20. Sign Form
EXPLAIN:
To sign the form, expand the Sign Off/Completed area, then click in the area where the statement states you have reviewed the note.
Click in this field and then click Done to complete the signing process for the form.
One additional step is now required, and that is to verify your signature by entering a password.
Then click OK to finish the process.
TRANSITION: Now let’s practice what we learned.

21. Practice – Surgical H&P
From the Surgery Clinic, highlight Patient B and access the Orthopedic Clinic Notes form. The patient presents with an Orthopedic consult, and the surgical procedure is 29883, Arthroscopy, Knee, Surgical w/ Meniscus Repair Medial & Lateral, right laterality. The patient is healthy overall and denies smoking and using alcohol. You document most answers using WNL, and then sign and complete the form.
ASSIST:
Move around room providing assistance as necessary.
ASK:
What questions do you have about filling in the Surgical H&P form?
INSTRUCT:
Provide directions to complete the exercise.
Log in to SQWM Documentation.
2. Select Surgery Clinic from the Census menu if not the default.
Select Orthopedics from the Unit dropdown.
Select Patient B and click to display dropdown menu.
Click Orthopedic Clinic Note.
Click Expand.
Fill in form with provided information and WNL as indicated.
Click in the Sign Off/Completed area and then select Done.
Enter Password and select OK.
TRANSITION: Now let’s let look at completing an Encounter form.

22. Document Encounter Info
EXPLAIN:
Encounter information is required to be included with every documented encounter. This information provides the VA with information that can be used for budgeting and planning.
Encounter information can be documented by selecting the Encounter Form link within the clinic note, just about the area where the note is signed.
The Encounter Form can also be accessed from the Encounter icon in the toolbar.
TRANSITION: Now let’s look at accessing the encounter form.

23. Open Encounter Form EXPLAIN:
After clicking the link, a dialog box displays to select the Encounter Form.
Confirm the form and select OK.
TRANSITION:
Now let’s look at how to complete the Encounter form.

24. Complete Encounter Information
EXPLAIN:
The Encounter Form displays and allows the user to document information pertaining to the visit type, reason for the visit, whether or not it was service related, etc.
Users see the encounter forms based on their specialty. The diagnosis dropdowns to choose from are based on the provider’ area of specialty and populate from ADT.
If not signed, the encounter form goes to the Pending worklist.
TRANSITION: Now that we have learned how to document forms, let’s look at putting in a request for surgery.

25. Request Surgery from Census
EXPLAIN:
There are patient specific options in the Surgery Clinic; click on the patient row and a dropdown menu displays with various options.
To begin the process of scheduling surgery from the Surgery Clinic Census, highlight the patient’s name, click to display the dropdown menu, and select Request for Surgery from the dropdown menu.
Request Surgery can also be selected at the bottom of the Clinic or Follow-up Note, as seen on the next slide.
The notes available are specific to the specialty of the surgeon accessing them. For example, an orthopedic surgeon sees Orthopedic notes listed.
TRANSITION:
Next let’s look at how to request surgery from the clinic note.

26. Request Surgery from Clinic Notes
EXPLAIN:
After documenting the history and physical for a new consult, if the resident or surgeon determines that surgery is indicated, they can make that request by clicking the Request Surgery field at the bottom of the form.
The Request for Surgery link is also available from the Documentation dropdown in the Surgery Clinic Census as seen previously. Selecting Request for Surgery also takes you to the form to request surgery.
TRANSITION:
Next let’s look at accessing the Surgery Request form to continue the request. .

27. Access Surgery Request Form
EXPLAIN:
A dialog box displays with the name of the form. Click OK, and the form opens.
TRANSITION: Next, we begin the request for surgery.

28. Request Surgery Form EXPLAIN:
The Request Surgery form displays and the first step in the process of scheduling or indicating for surgery is to click in the Request Surgery box.
TRANSITION: Next, we begin the request for surgery by entering the case information. .

29. Add Case – Info Tab EXPLAIN:
When you click Request for Surgery from the Surgery Clinic dropdown or Request Surgery field in the note, the Add Case page displays. Since you have already selected the patient, the patient should already be linked to the case, and the patient information pre-populates.
If it does not, enter the patient’s MRN and/or Last Name and select the Patient Manager icon; this takes you into Patient Manager to link the patient to the correct account number created during the registration process.
Enter the Patient Status, either inpatient or outpatient.
Select the surgeon from the Attending Surgeon dropdown menu.
The Add-on case defaults to No and can be changed if needed.
Enter the Anesthesia Type.
The Site defaults based on the room selected in the scheduling grid and the site association made in the room master table in database maintenance module.
The Service defaults based on the main surgeon’s service assigned in the employee master table in database maintenance module.
You can also enter information about any special needs related to the Pre-Op Clinic, or indicate any special request related to the surgery.
Fields that are indicated in Red must be completed prior to scheduling, or you will not be able to complete the process.
TRANSITION: Next we will look at entering the procedure information.

30. Add Case – Procedures Tab
EXPLAIN:
When entering information in the Procedure tab, the Surgeon field populates with the Attending surgeon; however, this can be changed if there is a main and secondary surgeon. Enter the procedure name or number; the name is an alpha search, the % or * on either side of a keyword can be used as a wild card search.
When Laterality is required, it displays in red and must be populated to proceed with scheduling the case.
Select Add when all fields are completed; multiple procedures can be added by repeating these steps.
Select the Surgery Indicated icon to place the case on the Misc Census or Request Room to add the case to the scheduling queue for scheduling.
If multiple cases are scheduled, a new VistA Concurrency field allows the user to select which VistA case a record is associated with.
TRANSITION: Let’s look at scheduling a VistA Concurrent Case.

31. Add Case – Multiple Procedures
EXPLAIN:
When adding multiple procedures, there is a simultaneous or consecutive flag to indicate if multiple procedures are being conducted at the same time or one after the other. This tells the system whether multiple pieces of equipment are needed and how the time should be scheduled.
The Procedure Auxiliary field in Scheduler is now called VistA concurrency, and defaults to VistA Case 1. VistA Case 2 can be selected, if needed, to send the information to VistA surgery as a different case.
TRANSITION: Next we enter the modification history.

32. Modification History EXPLAIN:
Modification history must be entered every time a change is made to a case, even if your name has been entered previously. You can also record if someone directed you to enter these procedures or make changes.
To enter the modification history, click Add. This enters the information for the current user. You may also click Comments to add any desired comments.
Click OK to close the Modification History window.
TRANSITION: Next we practice adding multiple cases.

33. Practice – Request Surgery
From the Surgery Clinic, highlight Patient B, click and access the Request for Surgery link. The patient presents with an Orthopedic consult, and the surgical procedure needed is 29883, Arthroscopy, Knee, Surgical w/ Meniscus Repair Medial & Lateral, right laterality. Select the Request Surgery field to access and complete the request.
ASSIST: Move around room providing assistance as necessary.
ASK: What questions do you have about requesting a case?
INSTRUCT:
Provide directions to complete the exercise.
1. Select Surgery Clinic from the Census menu, if not the default.
Select Orthopedics from the Unit dropdown.
Select Patient B and click to display dropdown menu.
Click Request for Surgery.
Under Surgery Indicated fields, click Request Surgery. The Add Case page displays in OR Scheduler.
Update info for Main Surgeon, Anesthesia, Status, Service and Times.
Click Procedure tab, and search for and enter procedure information.
Click Add.
Search for and enter procedure information for the next procedure and change the Vista Concurrency field to VistA case 2.
Click Request Room.
TRANSITION: Let’s look at how to complete the rest of the request surgery form.

34. Step 2: Complete Form EXPLAIN:
Once surgery has been indicated for the patient, the rest of the form can be completed using the same process as previously completing forms.
This form provides a place to enter information related to requested blood, frozen sections, latex allergies, anesthesia concerns, and other information that might be needed before proceeding with surgery.
TRANSITION: Next we look at how to complete and sign the form.

35. Sign Form
EXPLAIN:
As seen previously, the process for completing forms is the same, but signing off on a form requires a password be entered before the form is completed and can cross over to CPRS.
TRANSITION: When you sign the form, there is an additional step.

36. Enter Password to Sign EXPLAIN:
When a user finishes documenting a form, to lock it and allow for it to be transmitted, the user clicks Sign Off.
A Password Required prompt displays. The user can certify the document or cancel out if more information needs to be charted.
TRANSITION: Next, let’s look at how a provider can schedule a second procedure on a patient.

37. Request New Case EXPLAIN:
When providers select a patient who has already been indicated for surgery, the documentation dropdown displays a Request New Case option that allows them to schedule a new case if multiple cases are needed on the same patient.
An example of this might be if the patient needs cataract surgery, for the right eye this month, and the left eye next month. Using the New Case function means that they don’t need to come back into the clinic to Indicate Surgery again.
TRANSITION: Let’s review the elements of SQWM Documentation that we just covered.

38. Review We have covered the following topics: Log in and select census
Navigate windows
Indicate Patient for Surgery from Surgery Clinic
Add Case to Schedule
DISCUSS:
We have learned how to log in to the SQWM Documentation, how to navigate the Census windows, and how to indicate a case for surgery. We also learned how to add a case. What questions do you have about any of these processes?
ASK:
What are the three places where you can indicate a case for surgery?
What information do you need to fill out in order to add the case?
TRANSITION:
Next, we look at how a resident puts in a case for approval.

39. Residents’ Case for Approval
DISCUSS:
Residents enter the information to schedule a case, just as the surgeon would, but rather than a Surgery Indicated or Request Room icon, they have a Case for Approval icon which they select after filling in the appropriate information.
TRANSITION:
Next we look at how a surgeon approves a request.

40. Update or Approve Requests
EXPLAIN:
Residents may not be able to directly schedule surgery, so when a request is pending approval, it can be updated by the surgeon and scheduled at that time. A surgeon needs to approve the case for its status to change to Scheduled.
To do so, highlight the patient’s name and select Update Request to access the Update Case page.
Surgeons with approval privileges either update the request and schedule the surgery or approve the surgery in the approval queue.
There are three ways to do this:
From the Clinic Note, select Request Surgery.
From the dropdown menu, select Update Request.
From Clinic Follow-up Note, select Request Surgery.
TRANSITION: Let’s look at how to update a request that has been entered.

41. Update Case
EXPLAIN:
Once a case is scheduled, the case may change multiple times before the procedure actually takes place. The Update Case page allows you to make any changes necessary.
Enter the changes you need to make, then click Update or Request Room.
The surgeon or resident can also submit requests for surgery to be scheduled by a Scheduler or Charge Nurse.
When a new request is transmitted by the surgeon, the Schedule Requests icon on the OR Scheduler main page flashes.
From the Request Queue, the scheduler or charge nurse can see information in the request and schedule the request as needed.
TRANSITION: Let’s look at a case for approval in the Request queue.

42. Approve or Reject from Approval Queue
DISCUSS:
When residents submit cases for approval, the surgeon can approve several requests at one time. The Approval icon is available on the toolbar for the Misc Census and the Surgery Clinic Census.
Select the Approval icon to display the Request Approval page. From the Request Approval page, the surgeon can look it all the cases that need approval. These include those that show request approval or procedure request pending approval. The ability to do this is security driven. Surgeons can approve multiple cases at the same time.
For approval, select the Approve radio button.
The surgeon can either approve or reject the request. If the case is rejected, the surgeon must select a reason for the rejection.
Reasons for Rejection include: Not Available on Chosen Date, No Surgery Indicated, Patient not fit for Surgery, Further Medical Workup Needed, Further Surgical Workup Needed, Beyond Hospital Complexity or Capability, Wrong Attending Chosen, Different Surgery Needed.
When a case is approved here, it changes to Surgery Indicated and adds it to the Misc Census. To send the case to be scheduled, from the Misc Census, update the case to Request Room to send it to the mailbox to be scheduled.
TRANSITION:
Next let’s look at follow up notes that can be entered in SQWM.

43. Follow-up Clinic Note EXPLAIN:
The follow- up Clinic Note is documented the in the same way as the other forms. Clicking in the field displays a pick list of options to choose from, or a field can be selected to enter text.
TRANSITION:
Let’s look at how to access procedure notes in SQWM.

44. Procedure Note EXPLAIN:
Whenever surgeons or residents perform procedures outside of the operating room, they must create a procedure note to document them. Procedure notes are also used as progress notes for patients. The Anesthesia application includes a procedure documentation function that gives users the ability to document information online in a standardized template format, using the standardized procedure templates available.
The Procedure Note is patient specific and must be in a proper format. To access the procedure templates, highlight the patient and click to access the documentation dropdown or click the Procedures icon on the toolbar to open the template selections.
When the Procedure Documentation window displays, select the folder showing a procedure group and then select the specific procedure that you want to document.
TRANSITION:
Let’s look at how to document a procedure note.

45. Document Procedures EXPLAIN:
Verify that the date and default information is correct, or make changes if needed. In the Time text box, enter the time in hh:mm (24 hr clock) format.
Select the Attending text box and enter the name of the attending physician. The Physician’s name displays in the text box. Select the Location performed text box and enter the location. If you are logged in as the attending, you can note that you were physically present during the procedure by selecting the Attending Physically Present check box.
The software provides short cuts for the verbiage used in the note. When you click View Note, the text pre-populates. You can add to or edit this verbiage.
Procedure notes are available for 7 days. To search for a previous note, enter the date range and click Search. The procedure notes for the specified date range display in the grid in the upper part of the page.
TRANSITION:
Next let’s look at a completed procedure note.

46. Procedure Note EXPLAIN:
Clicking Sign saves the note. You can save the note by signing and then go back and review the procedure note at a later time. It displays on the Pending Work Census until it is properly signed and locked.
To access the note, search for the patient in OR Census, select Procedure Note from the dropdown and then access the unlocked note and complete the sign and lock process.
You must use Sign and Lock to transmit the note to CPRS.
NOTE:
It is important to get in the habit of documenting as you do procedures to keep the records accurate and current.
TRANSITION:
Next, let’s practice documenting a procedure note in SQWM.

47. Practice – Procedure Note
For patient A, create a Procedure Note for an Attending Pre-Procedure and Admit Note performed in the pre-op holding area. You document the note and save it to review later.
ASSIST:
Move around room providing assistance as necessary.
ASK:
What questions do you have about entering a procedure note?
INSTRUCT:
Provide directions to complete the exercise.
Log in to SQWM Documentation.
Select OR Census.
Click Patient A.
Click Operative /Procedure Note from the dropdown.
Select the template folder for Procedure Templates.
Select the Standard Notes folder.
Select Attending Pre-Procedure & Admit Note for the Procedure.
Enter relevant data.
Click View Note.
Click Sign to save the note. (We will complete the note in a later exercise)
Click Back to go back to the census.
Debrief the exercise by reinforcing the purpose of the exercise, asking questions to check understanding and linking this exercise to previous knowledge.
TRANSITION:
Next, let’s look at OR Census

48. OR Census Overview DISCUSS:
When users select OR Census, the patients assigned to them for the current day populates automatically.
To display patients for a specific date census, in the date fields, select the From Date and the To Date on which you wish to search. To retrieve all patients for a specific date, do not enter any other information in the patient search text boxes. All Patients that are scheduled for that date displays.
To search for a specific patient, enter the last name in the Last Name field and click Search. Other search options include specific personnel, such as attending, resident or anesthesiologist, as well as case number or room number.
Search fields can be used to limit the results seen in the OR Census display area. In order to search on the various roles (i.e. surgeon, anesthetist) these roles need to have been assigned via the scheduling system.
As users log in to the application, if they are assigned to one of the roles in the search area, their name defaults in the initial search. If the user has not been assigned to cases, they can select Clear and Search to remove the provider criteria.
Column headings include Name, OR Scheduled, Scheduled Time, SSN, DOB, Assigned Personnel (Anesthesiologist, CRNA, Resident, Surgeon), Preop Eval, Case Number, PAT Concerns, and Clinic Location. The columns can be sorted by double clicking on the column header.
TRANSITION:
Next, let’s look at the documentation options in OR Census

49. OR Census Documentation
DISCUSS:
The documentation available from OR Census includes the Operative/Procedure Note and the Surgical H&P, which we have already seen as the clinic note.
Other documentation includes a Pre-Procedure Reassessment, a brief Operative Note that is completed by the surgeon following surgery and a Dictated Note Report. A Discharge Instruction note is also available.
TRANSITION:
Next, let’s look at the documenting the operative note.

50. Operative Note DISCUSS:
Available operative note templates include the generic Brief Operative Note as well as a Cardiac Operative Note, Transplant Operative Note and an ENT Operative Note.
TRANSITION:
Next, let’s look at the brief operative note.

51. Brief Operative Note EXPLAIN:
The form for the operative note is completed the same way as other forms.
One change in VA policy, however, is that when multiple procedures are performed, one surgeon enters the brief operative note and the other surgeons append the first note.
Previously, concurrent procedures using different doctors were scheduled and documented as separate cases. This is a change for the VA in both scheduling and documenting.
TRANSITION:
Next, let’s practice documenting a brief operative note.

52. Practice – Brief Operative Note
For patient B, create a brief operative note for the meniscus repair surgery on the right knee. The surgical procedure is 29883, Arthroscopy, Knee, Surgical w/ Meniscus Repair Medial & Lateral, right laterality. The procedure was performed as expected with no complications.
ASSIST:
Move around room providing assistance as necessary.
ASK:
What questions do you have about entering an operative note?
INSTRUCT:
Provide directions to complete the exercise.
Log in to SQWM Documentation.
Select OR Census.
Click Patient A.
Click Brief Operative Note.
Enter relevant data.
Click Sign and Lock to save and transmit the note.
Click Back to go back to the census.
TRANSITION:
Next, let’s look at the dictated note report.

53. Dictated Note Report EXPLAIN:
The Dictated Note report provides a place to record the date the surgery was performed, the procedure and the supervision level provided. The provider can then sign the note.
TRANSITION:
Next, let’s review the documentation options in OR Census

54. Review We have covered the following topics:
Enter data in Surgical H&P form
Create a Procedure Note
Create a Clinic Note
Create Brief Operative Note
Create Dictated Note Report
REVIEW:
In this session, we learned how to access the various documentation forms used by the surgeon and resident. We also discussed how to enter data in the Surgical H&P and how to use WNL and the NC features and how to create a procedure note, a brief operative note and a dictated note report.
What questions do you have about any of those processes?
ASK:
What kind of procedure notes do you most commonly create?
TRANSITION:
Next we will look at using the Pending Work Census to sign or cosign documentation.

55. Pending Work Census Options
EXPLAIN:
The Pending Work Census shows unlocked forms and notes that need signatures. It can also be accessed by clicking WorkList.
To access the Pending Work Census and co-sign a note, click Census and select Pending Work Census. Click in any column for the patient.
The unsigned procedure note or unsigned form opens allowing you to continue documenting and then sign the form.

56. Practice – Pending Work
You notice that the Pending Work Census indicates that the note you completed earlier is unlocked. First view the note, and then sign and lock the note.
ASSIST:
Move around room providing assistance as necessary.
ASK:
What questions do you have about the Pending Work Census?
INSTRUCT:
Provide directions to complete the exercise.
Log in to SQWM Documentation.
Click Census and select Pending Work Census.
Select the unsigned form.
Select Sign and Lock area.
Click in the I have reviewed form area to sign.
Click Done.
Enter Password and click OK.

57. Miscellaneous Census EXPLAIN:
The Misc Census is also referred to as the Waitlist Census. A patient is placed on the Miscellaneous/Waitlist Census when indicated for surgery and stays there until the surgery is performed and the out of room time is entered for the OR in the Nursing Documentation module.
Two important columns on this census are Status and DOL. DOL refers to Days on List, which starts with zero and shows how long the patient waited to have surgery. Days on List is counted from the time surgery is indicated until the patient is marked out of room in Periop Nursing Documentation. The status changes to Completed at this point, and drops off the Misc Census.
The Status column displays patient statuses such as Surgery Indicated, Pending Request, and Pending Medical Clearance. If the surgery is delayed as a result of the patient not being medically ready the status is Pending Medical Clearance. Although Completed cases are no longer displayed on the Misc Census, they can be searched for and viewed.
Other columns include patient’s Name, DOB, Gender, SSN, which all populate from ADT.
Once the patient list displays, click the patient to display the dropdown options for that patient.
Options available include the Surgical Readiness Status Form and links to Labs and CPRS, which are available from the Census dropdowns.
TRANSITION: Let’s look at search options for the Misc Census.

58. Misc Census Search Options
EXPLAIN:
The search options for the Misc Census are the same as those for the Surgery Clinic Census. To see patients for a specific date, select the clinic under Unit.
You can select multiple units or use the multi-select option to select all units. A default unit can also be designated in Security setup.
Enter a date range, or if looking for today’s patients only, leave it at the default of the current date.
Click Search. The entries matching your search criteria display. The columns can be sorted by double clicking the column header.
As with the Surgery Clinic Census, you can export this list if you have the correct privileges.
TRANSITION: Now, let’s look at some of the Status categories and what they mean.

59. Status Options EXPLAIN: Patients can be searched for by status:
Acton Required - Items required for clearance for surgery display on the MISC Census under the Actions column. Use the Update link to update the case. Days on List continues.
Canceled - Stops counting Days on List. Cancelled status comes from Clinical Documentation or Scheduler.
Canceled Pending Reschedule - When a case is cancelled in Scheduler, and Return to Misc Census is selected from the cancel case window. This option is used to mark a patient for further workup.
Clinic - all consults have an initial status of Clinic.
Completed - Cases fall off the Misc Census but can be searched for when needed
Deceased comes across from ADT.
Discharged from service status displays when the patient is dismissed by the surgeon.
Surgery Indicated shows whenever surgery is approved. Procedure Requests can be listed as Pending Approval, Approved Or Rejected.
TRANSITION: Let’s look at how to put a case back on the Misc census if it needs to be cancelled.

60. Cancel and Return to Misc Census
EXPLAIN:
Once a case has been scheduled for surgery in OR Scheduler, there may be occasions when that case needs to be cancelled, but the surgery is still needed. In these situations you want the case to remain on the Misc Census to mark the patient for further workup.
To cancel a case that has been scheduled in OR Scheduler, the scheduler locates the case either in the main OR Scheduler window or a Query. Click on the case and select the Cancel Case icon on the toolbar.
The Cancel Case window displays. Enter a Reason for Canceling Case by selecting a reason from the List of Cancellation Reasons dropdown or by entering text in the free text field.
Select the Return to Misc Census button to put the case back on the Misc Census for further testing or follow up.
TRANSITION: Now, let’s look at the features of the Surgical Readiness Status form.

61. Surgical Readiness Status Form
EXPLAIN:
The person assigned to monitor the surgical waitlist usually also fills out the Surgical Readiness Status Form. Patient wait times begin being calculated when surgery is indicated. In order to prevent excessive wait times, it is important to monitor the issues preventing surgery and keep it on schedule.
The Surgical Readiness Status Form can be used to track tests that need to be completed, or other issues that are impacting surgery.
Wait times can be placed in suspense from any patient decision not to have or to delay surgery. The patient can have up to three instances where the surgery is placed into suspense, after that the surgery is rescheduled.
The surgeon documents routine items through Routine Tests/Studies Needed on the H & P. These items flow to the Surgical Readiness Status form and do NOT display on the Misc census.
Items required for clearance for surgery are documented under the variable: Required for Clearance. These items DO display on the Misc Census under the Actions column.
TRANSITION:
Next, let’s look at the features of the VASQIP Risk Assessment.

62. VASQIP Risk Assessment
DISCUSS:
The VA’s Surgical Quality Improvement Program gathers information from all surgical patients and uses that information to assess and improve surgical outcomes for the VA. The Risk Calc icon in the toolbar accesses the VASQIP Risk form, which can be used to calculate the VASQIP risk assessment.
This accumulated information provides the information used to calculate surgical risk for the surgeon using the Risk Calculator.
To use the risk calculator form, fill in the data just like any other v-form that we have already seen, and then select Calculate Risk.
TRANSITION:
Does anyone have questions?

63. Questions? Session Wrap-Up ASK:
What are the three ways that you can indicate a case for surgery?
What information do you need to fill out in order to add the case?
What kind of procedure notes do you most commonly create?
Ask for any questions on the practice exercises. Are there any steps or processes that are unclear?
DISCUSS:
Any outstanding questions from the parking lot?
TRANSITION:
Next let’s look at some features of the Tracker program that can help users follow the status of a patient having surgery.

64. Track Surgery EXPLAIN:
The Tracker module allows users to better manage resources during the day of surgery. Tracker not only tracks where patients are in their Pathway (pre-op, intra- op, post-op), it also tracks any resource for real time conflict checking. (e.g. Instrument sets, equipment and staffing).
This module also allows you to set up your staffing needs. The routing of information is based on the staff that is available and the routing can be configured by the end-user.
Room changes, staff changes and time updates are all real time and feed in from the clinical documentation packages for more accurate logging.
TRANSITION:
Let’s look at the meaning of the Tracker icons.

65. Tracker Icons Operative Consent IV in Place Staff Note Complete NPO
H&P Complete
Bed Available
Isolation Status
Blood Consent
IV in Place
NPO
Labs/Tests
EKG
Site Physically Marked
Staff Surgeon Visit Complete
DISCUSS:
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.
TRANSITION:
Let’s look at the additional information available in the Case Label drill down.

66. 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.
TRANSITION:
Let’s look at the additional information available in the Case Labels.

67. 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
TRANSITION:
Let’s practice what we learned.

68. Surgery Real World Scenario
Patient C presents to the Orthopedic Surgery Clinic and you decide during your exam that the patient needs to be scheduled for a left shoulder arthroscopy with subacromal decompression. Find Patient C from Surgery Clinic Census and complete the H&P and request surgery. After you perform the surgery, you create a brief op note. You indicate that EBL was less than 50 cc and document that he was given 700 ml lactated ringers. You had to use mitek mini anchors and the patient received 2 gms of Ancef on the way to the OR. You are documenting your note but get called back to the OR before signing, so you close the note, and access the Pending Worklist to complete the note.
ASSIST: Move around room providing assistance as necessary.
ASK:
What questions do you have about any of the processes that we have covered?
INSTRUCT:
Provide directions to complete the exercise.
Log in to SQWM Documentation.
Select Surgery Clinic from the Census menu if not the default.
Select Orthopedics from the Unit dropdown.
Select Patient C and click to display dropdown menu.
Click Orthopedic Clinic Note.
Fill in form with provided information and WNL as indicated.
Under Surgery Indicated fields, click Request Surgery. The Add Case page displays in OR Scheduler.
Update info for Main Surgeon, Anesthesia, Status, Service and Times.
Click Procedure tab, and search for and enter procedure information.
Click Request Room.
Select OR Census.
Select Patient C.
Click Brief Operative Note.
Enter relevant data.
Click Back to go back to the census.
Click Census and select Pending Work Census.
Select the unsigned note to open.
Expand the Sign and Lock area, then click the statement saying that you have reviewed the note.
Enter password.
Click OK.

69. 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.

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