18. 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. Converting Reports
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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
43. FLORIDA,FRANK (020-30-3021) MEDICAL RECORD NURSE INTRAOPERATIVE REPORT - CASE #267226 PAGE 1 Operating Room: WX OR3 Surgical Priority: ELECTIVE Patient in Hold: FEB 12, 2004 07:30 Patient in OR: FEB 12, 2004 08:00 Operation Begin: FEB 12, 2004 08:58 Operation End: FEB 12, 2004 12:10 Surgeon in OR: FEB 12, 2004 07:55 Patient Out OR: FEB 12, 2004 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
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45. Press <return> to continue, 'A' to access Nurse Intraoperative Report functions, or '^' to exit: A MONTANA,JOHNNY ( 111-12-111P ) Case #435251 - 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>
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49. >>> 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. Nurse Intraoperative Report Addenda
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51. MONTANA,JOHNNY (111-12-111P) Case #435251 – MAY 1,2004 An addendum to each of the following electronically signed document(s) is required: Nurse Intraoperative Report - Case # 435251 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>
52. Addendum to Nurse Intraoperative Report for Case #435251 – MAY 1,2004 Patient: MONTANA,JOHNNY (111-12-111P) ------------------------------------------------------------------------------------------------------ The Count Verifier field was changed from LANSING,EMILY to VANDERGRIFT,JOHN Do you want to add a comment? YES// NO Enter your Current Signature Code: XXXXX SIGNATURE VERIFIED
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54. MEDICAL RECORD NURSE INTRAOPERATIVE REPORT PAGE 1 Case # 155 Operating Room: OR1 Surgical Priority: ELECTIVE Patient in Hold: MAY 01, 2004 09:00 Patient in OR: MAY 01, 2004 09:30 Operation Begin: MAY 01, 2004 09:45 Operation End: MAY 01, 2004 12:30 Surgeon in OR: NOT ENTERED Patient Out OR: MAY 01, 2004 12:40 Major Operations Performed: Primary: CHOLECYSTECTOMY Wound Classification: CLEAN Operation Disposition: PACU (RECOVERY ROOM) Discharged Via: STRETCHER Surgeon: MIAMI,STEVEN First Assist: TOPEKA, MARK Attend Surg: MIAMI,STEVEN Second Assist: N/A Anesthetist: BOISE,WILLIAM Assistant Anesth: COLUMBUS,ANGELA OR Support Personnel: Scrubbed Circulating DES MOINES,DIANE AUGUSTA,DON Valid Consent/ID Band Confirmed By: AUGUSTA,DON Skin Prep By: DES MOINES,DIANE Skin Prep Agent: N/A Preop Shave By: DES MOINES,DIANE Surgery Position(s): SUPINE Placed: N/A Restraints and Position Aids: SAFETY STRAP Applied By: N/A Electrocautery Unit: 7299 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, 2004 09:55 Route: INTRAVENOUS Dosage: 10mg Ordered By: MIAMI,STEVEN Admin By: AUGUSTA,DON Comments: N/A Irrigation Solution(s): NORMAL SALINE Time Used: MAY 01, 2001 10:05 Amount: 1000 Provider: AUGUSTA,DON Sponge Count: YES Sharps Count: YES Instrument Count: YES Counter: AUGUSTA,DON Counts Verified By: DES MOINES,DIANE 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
55. . . . Sponge Count: YES Sharps Count: YES Instrument Count: YES Counter: AUGUSTA,DON Counts Verified By: DES MOINES,DIANE 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/ DON AUGUSTA DON AUGUSTA 05/08/01 14:59 05/21/2004 11:37 ADDENDUM The Count Verifier field was changed from LANSING,EMILY to VANDERGRIFT,JOHN Signed by: es/ DON AUGUSTA DON AUGUSTA 05/21/2004 11:37
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57. Additional References Documentation including User, Technical Manuals and Release Notes can be found on the Electronic Signature for Operative Reports VDL Web page. http://www.va.gov/vdl/Clinical.asp?appID=103
61. TIU This is where Reports, Discharge Summaries and Progress Notes are stored and maintained.
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.
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?
64. ANSWER: You will need to work together as a TEAM to complete the Pre-Installation Worksheet.
65. Why is this so Critical? Because your decisions reflect the policies and practices of your hospital.
68. 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 Clinical Documents
69. The Surgical Reports will be activated upon Installation The reports won’t be usable until implementation of SR*3.0*100
70. What functionality will be used to control and restrict access to the Surgery Documents within TIU and CPRS ? Answer: Authorization Subscription Utility (ASU)
71. No TIU Business Rules will be exported with TIU*1.0*112. Sites will need to devise their own policies.
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.
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
75. CPRS GUI Surgery Tab All Surgery documents will display from this tab.
This presentation has been designed to provide general information about the Electronic Signature for Operative Reports project and in some areas specific details.
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