Electronic Medical Records Slide ShowPresentation Transcript
ELECTRONIC MEDICAL RECORDS OPTIME EXPERIENCE
Perioperative Experience and Skills Case Request and Scheduling PreOp IntraOp PostOp (PACU) Other Experience and Training
Case Request and Scheduling
Worked with surgeons to initiate surgical case requests (clinic visit or hospital admission) including case planning, day of surgery orders and linking of related encounters.
Assisted clinic schedulers in locating and reviewing case request questionnaire, documenting patient follow up, PreOp and PostOp appointments, labs, and patient information.
Supported OR scheduler in creating of case requests as required. Assisted in their understanding of steps required to make adjustments to procedure location and name , staffing, equipment additions, and case times as required.
Experienced in CPOE
Knowledge of electronic White Board (GreaseBoard) functions: Locating correct patient and surgical case, verifying correct orders and existence of proper History and Physical, and chart look up and review.
Trained PreOp RNs in completing patient verification, assessment information, medication history and where to documenting the periop nursing care plans.
Demonstrated knowledge on where and when to document important PreOp notes.
Extensive Operating room experience.
Accompanied circulators and/ or transport staff when patients were being transferred from floor to OR to ensure that documentation was accurate and complete.
Worked at elbow level with circulators in documenting intraop information such as catheters and drains, medication administration, PYXIS overrides as needed, site documentation and required comments.
Supported circulators in documenting in the surgical log including Time Out w/ Briefing form, staff, visitors, supplies, equipment, implants as required, and other important information.
Advised how to enter information otherwise not listed as options.
Audited logs for accuracy.
Worked with PACU staff in recovery documentation and medication administration including meds not given, overdue or cancelled.
Assisted in transfer and discharge documentation and locating and printing discharge instructions.
Accompanied transport and/or recovery RN to floor to assist in proper admission to floor unit.
Additional Experience and Training Contributed to18 EPIC Go-Lives Received Classroom Training in: