Intraoperative EPIC Documentation Teaching Standard - PowerPoint Presentation

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Intraoperative EPIC Documentation Teaching Standard

Megan Hellrung, BSN, RN & Kristi Schuessler, BSN, RN, CNOR

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Review current EPIC Op-Time documentation practices amongst AIP OR NursesIdentify both collective and inconsistent documentations practices

Clarify EPIC Op-Time documentation criteria

Regulate documentation practices through development of standards to guide consistent practice and continuity of care

Objectives

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AIP OR EPIC Charting Guidelines

Survey was distributed to assess

OR Nurses documentation practices in two groups - Service Specialists/Current Staff Nurse (off orientation >1 year)

- Recent/Current Orientee Nurse (hire date within 1 year)The surveys response rates: - 41/115 Service Specialists/Current Staff Nurses = 36% - 19/30 Recent/Current Orientee Nurses = 63%

Background

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Literature review to assess recent evidence-based practices related to electronic healthcare documentation

- Association of Operating Room Nurses (AORN) Recommended Practices for Perioperative Health Care Information Management -

http://www.aornstandards.org/content/1/SEC28.body

Literature review of UCH Policies/Procedures and Guidelines applicable to Op-Time documentation - Surgical Counts - Specimen Collection

Background, continued

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Organize group of expert-opinion stakeholders to review and analyze each section of the Op-Time Chart

- Inpatient OR Nurse Manager, Inpatient OR Associate Nurse Manager, Inpatient OR Clinical Nurse Educator, Senior Risk Manager, OR EPIC Superuser

, Perioperative Patient Safety Specialist, Perioperative Clinical

ScholarCollaborate with additional EPIC personnel and UCH healthcare professionals to obtain secondary support for specialty documentation - Service Specialists, Nursing Practice Guideline Committee, Information Technology Trainer, Systems Analyst RNCreation of Teaching Standard: Intraoperative EPIC Documentation tool

Background, continued

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Sections of the Intraoperative Chart

Procedure

Procedures

Supplies

Equipment/Instruments

Intra-op Medications

Implants

Specimens

Orders

Order Sets

Clinician Communication

Timing Events

Pre-Incision Summary SBAR Allergies Implant History Staff Counts Pre-Op Skin Site Prep Positioning Timeout Delay Nursing Notes Lines/Drains Braden Scale

Closing

Incision/Wounds

Site Completion

Post-Op Skin

PNDS

Verify

Debrief/Handoff

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“Cut Time” populated only upon

incision

(or start of intervention if no incision)“Sweep” populated upon completion of the MWE (Methodical Wound Exam)“Close Time” when

drapes are removed

from patient“Ready for OR Discharge” – when patient is stable and ready for transfer (even if on PACU hold)Should always be populatedIntraoperative Timing Events

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Allergies must be marked as reviewed prior to procedure start timeIf patient’s prior implants populate here and are being explanted, document explant date and time

Allergies, Implant History

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Accurate “Time In” and “Time Out” records must be kept

If staff member leaves for a break, populate “Time Out”. When they return, populate “Time In”

Temporary relief person documented as “Circulator Relief/Scrub Relief

”

Permanent relief person documented as “Circulator/Scrub”Company reps are documented as “Vendor”Students, observers, etc are documented as “Visitor”

Document support staff (Radiology,

Neuromonitoring

,

etc

)

Staff

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Remember to document the time and surgeon completing the MWE

If count is incorrect – specify only portion that was incorrect (i.e. sponges incorrect, sharps/instruments correct)

“Counted By” – Scrub“Verified By” - CirculatorSecond “Closing” count specified as “Instrument Check Fluoro

/

Xray” for Anterior Lumbar Interbody Fusion (ALIF), XLIF (lateral)Document surgeon’s name as “verified by” and “counted by”Wound Packing of countable itemsCounts

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An overall skin assessment is to be completed in the

Pre-Op area

Can be completed with patient verbally or via visual assessment  Site prep should include surgical site, laterality and hair removal (if applicable) and prep solution

If multiple surgical site(s) planned for a procedure(s), each prep site must be entered individually

If an inclusive body surface area prep is required, a single selection of site option or selection of multiple sites for one inclusive procedure document as a single entryIf multiple preps are utilized on same surgical site, each prep solution must be selected

Pre-Op Skin, Site Prep

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Primary positioning

of the patient required for a surgical procedure(s) must be

documentedAll surgical team members involved in positioning the patient must be documented.

- Anesthesia staff must be included related to their responsibility and control of the patient’s airway.The time final positioning of the patient occurs must be

documented

-

I

mportant

to determine the length of time a patient has been

in position, supports assessment for injury and care to maintain the patient’s skin integrityAny additional positioning that occur throughout a single procedure requires a supplementary positioning entryPositioning

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Must be completed prior to the start of any

procedure

“OR-Pre Incision” is appropriate for all

OR surgical

procedures or completed as a bedside procedures Procedure timeout questions must be addressed and confirmed prior to timeout verification (i.e. hard-stop questions)

B

riefing

questions should all be addressed and documented as

“Yes”

when members of the surgical team discuss

if

the patient requires the listed care interventionsTimeout

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A complication that prevents a

first

case from starting at the scheduled time or causes turnover time to be greater than thirty minutes must be documented

“No

Delay”= patient arrives in the OR on time/room turnover is completed and surgical team ready within thirty minutes “ No Delay” = A scheduled case starts later than originally planned but turnover from the previous case was completed in thirty minutes

“No Delay”

= If a Request for Time (RFT) follows a completed scheduled

case

OR

RN is responsible to ensure the delay type and delay reason reflects the anesthesia record’s delay type and delay

reason

The delay length is the amount of time documented in minutes before the patient was brought back to OR and/or the number of minutes over thirty minutes allotted for turnover. Delay

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Must document:Preop

Interview/Patient education (AORN Guidelines for Perioperative Practice)

Communication with patient’s familyWound packing (if applicable)Placement date and timeName of person placing the packing

Location

Quantity of items being placedDate and time of removal, if applicableNursing Notes

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Lines and airways placed by the anesthesia provider are documented by the anesthesia provider

Airways placed by the surgeon (i.e.

trach) are documented by the OR nurseDrains placed by the surgeon are documented by the OR nurseIf patient arrives to OR with drains in place, OR nurse should document an assessment (but not if placed in the OR)

Assign a number to drain to distinguish it from other drains

Document removal of drainsDocument assessment of urine upon placement of FoleyLines, Drains, Airways

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Braden Scale documented by pre-op RNIf not completed by pre-op RN, OR RN must document

Document thinking of patient pre-operatively, not anesthetized

ProceduresDocument Description, Laterality, Type of Anesthesia, Wound Class for each panel (if applicable)Verify wound class with surgeon

Laterality documented as “N/A” if midline or no laterality – not “Bilateral”

Braden Scale, Procedures

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If documenting a one-time supply, at a minimum must document:Supply name

Quantity used or wasted

Name of the manufacturerManufacturer number (i.e. reference number or model number)

Document a reason when a supply is wasted

If patient has Latex allergy – ensure these items are either removed or at “0”Supplies

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Equipment that is applied directly to the patient and has the risk to cause a thermal injury must be documented

Device name, serial

number and/or hospital code

and

the initial settings the device will be applied to the patientEquipment/Instruments

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Medication administration in the OR may occur through direct administration or from the sterile field

If

a medication is administered to in

multiple doses (i.e. local injection prior to incision or local injection prior to dressing application), each individual administration must be documented as a separate

entry (time stamped).It is appropriate to select “Other” when medication is administered indirectly to the patient (i.e. bladder irrigation).

It

is appropriate to document procedure

“Cut Time”

as the administration time for PRN medications that are present on the sterile field and are required for the

procedure start (i.e. irrigation)

Intra-Op Medications

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The action of an implant either on the sterile field or that has reached the patient must be documented

.

If

an implant is being removed from a patient for lawsuit/legal reasons, it must be documented as “Explanted” in either the Implant History screen if applicable, or within the Implant screen.

- A Pathology Requisition may also be completed for explanted items for lawsuit/legal reasons, per surgeon preference (Please refer to XX. Specimens, A, #5, b.). When an implant is a tissue, organ or tissue derivatives, the TrackCore barcode may be scanned, if applicable to populate the implant and required implant fields.

If an implant does not have a TrackCore barcode or will not scan, the OR RN must enter the tissue implant manually into the

chart. The

OR RN must manually enter the ITM number below the barcode as the TrackCore ID.

Implants

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When a specimen is obtained but

surgeon

requests that the specimen not be sent for pathology examination, document a Nursing Note acknowledging the surgeon’s

request

The specimen ID should be identified as a numerical value to support the organization of specimen collection (i.e. Permanent, Frozen or Fresh specified as 1, 2, 3 etc.)Specimens that are removed from a patient for lawsuit/legal reasons must be documented as a requisition

per

legal obligations.

If

a specimen/evidence is to be given to the responsible law enforcement officer, a Nursing Note must be documented acknowledging the transfer of the

specimen/evidence

Specimens

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Any Laboratory order or Central Supply order requested or completed within the OR must be

signed

The order mode appropriate for intraoperative Orders include: “Verbal, with read back verification” or “Telephone, with read back verification

”.

Central Supply orders should utilize the comment section to identify which OR is requesting the item(s), a reference to who will pick up the item(s) and the OR phone number as a contact

Orders

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Document orders in “Orders” section, not Order Sets

Clinician Communication

Transfer phone call with critical results to anesthesia provider (no documentation necessary)If RN does take the information and communicate it to anesthesia provider/surgeon, must documentRecommend communication with pathologist (i.e. frozen section) documented here

Only if RN relays information to surgeon

Do not document information called about another patient in your patient’s chartOrder Sets, Clinician Communication

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Robot Console Start / Robot Console StopVein In / Vein Out for CABG procedures

Time of incision on leg, then time vein removed from leg

No other timing events documented here at this timeTiming Events

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Pre-existingNo if new incision

Yes if the patient has a pre-existing incision that has a “Final Assessment” date and time documented (document a new incision and mark “Yes” for pre-existing)

If incision is pre-existing and does not have a “Final Assessment” date and time documented, do not create a new incision entry, and document an assessment of the existing incisionScope Sites

Only populate for creation of multiple scope sites (i.e. laparoscopic procedures)

Do not populate if multiple incisions (but not scope sites)If multiple incisions on same body part, new incision entries must be created for each incisionIncisions/Wounds

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Existing burn – Dressing Assessment (often “removed”), type of graft used, type of dressing applied

Non-wound packing

Placement date and timeName of person placing the packingLocation (must be specified as ear, eye, mouth, nose, or vagina)

Quantity of items being placed

Date and time of removal (if removed while in the OR)Wound Packing does not exist in EPIC. Document as non-wound packing with a location comment, and also make a Nursing NoteTelfa “wicks” should be considered packing, as they have been retained

Incisions/Wounds Continued

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Document site completion for each surgical siteDo not document wound packing under site completion

Site Completion

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Add any variance from

Pre-Op Skin assessment

Assess any additional interventions directly applied to the skin including tourniquet (if applicable), grounding, positioning, warming, and operative sites.

OR RN must review pre-populated “Outcome Group” phrases to ensure that nursing contributions applied are documented

If a pre-populated diagnosis in the “Outcome Group” does not apply, it is appropriate to deselect the phraseIf a pre-populated intervention(s) descending “Outcome Group” phrases does not apply it is appropriate to deselect the intervention(s)

Post-Op Skin, PNDS

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Verification is to be completed after the patient has been safely transferred to the next phase of care and handoff report has been

completed

L

egal electronic signature authenticating the information in the chart is accurate, reflecting the factual events of the procedure and care provided within the OR.

The OR RN must return to the OR to complete a final review of the chart.

Verify

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Completion of the Debrief/Handoff should be done at the end of the case after the patient has been safely transferred to the next phase of

care

and handoff report has been completedThe OR RN should utilize the Debrief/Handoff tool during staff changes such as breaks/lunches or permanent shift relief or during handoff report in phase of care change as a means to provide standardized report

Debrief/Handoff

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OR Pre-Op Checklist

OR

RN to complete when the OR RN will act as the primary nurse for the patient throughout the Intraoperative care setting

Transferring a Patient

Receiving unit must document patient transferEditing the ChartIf chart is “read-only”, must create an addendum to the chart to make necessary editsProcedure not PerformedDocument “Procedure not Performed” under “More Actions” in the EPIC sidebarInclude whether canceled “In

Preop

”, “Before Induction”, or “After Induction

”

Chart does not need to be verified if before “Cut Time”

Additional Information

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Transplant Charting

Transplant times under “

Txp Surgical Forms”Document pre-incision verification of donor and recipient blood types between the OR RN and the surgeon by selecting “ABO Pre-Organ Arrival Verification” in the “Timeout” sectionDocument verification of organ and donor/recipient blood types between the OR RN and the surgeon at the time the organ has entered the room by selecting “ABO Organ Verification” in the “Timeout”

section

If the patient is an organ donor only and is not receiving a transplanted organ, then a single verification must be documented in the “Timeout” section under “ABO Organ Recovery Verification”. Additional Information, continued

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Survey results, literature review and expert stakeholders/healthcare professionals act as the foundation backing and building this tool

Several updates for standardization to support OR RN organization, efficiency and continuity of care through EPIC documentation

Readily accessible tool for review and reference can be resourced via AIP OR Weebly education site: http

://

uchor.weebly.com/documentation-teaching-tool.htmlConclusion

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Beyea, S.C. (1999). Standardized language-making nursing practice count.

AORN Journal

, 70(5): 831-832, 834, 837-838. (LOE VII)Braden, B. & Bergstrom, N. (1988). Braden scale for predicting pressure sore risk. In Prevention Plus: Home of the Braden Scale. Retrieved March 18, 2015, from

http://www.bradenscale.com/images/bradenscale.pdf (LOE VIII)Garner, JS. (1985) CDC guideline for prevention of surgical wound infections [Electronic version]. Infect Control, 7(3):193-200. (LOE VII)Giarrizzo-Wilson, S., Anderson, C.A., Hughes, A.B., & Klein, C. A. (March 9, 2012). Guideline for healthcare information management. In Guidelines for Perioperative Practice. Retrieved from

http://www.aornstandards.org/content/1/SEC28.body

(LOE VII)

Kleinbeck

, S.V.M. (1999). Development of the Perioperative Nursing Data Set.

AORN Journal

, 70(1): 15-18, 21-23, 26-28. (LOE VII)

Price, M. C., Whitney, J. D., & King, C. A. (2005). Development of a risk assessment tool for intraoperative pressure ulcers [Electronic version]. JWOCN, 19-32. (LOE V)References