the day in the life of the or nurse · 7/18/2018 · accessing the patient’s chart to access the...

Version Date 7.18.2018 of 72 Property of

SurgiNet: The Day in the Life of an OR Nurse


Agenda

Topic

Scheduling a Rapid Appointment

Tracking Board

Case Documentation Manager

Intraoperative Documentation

Cultures and Specimens

Implants and Tissue Log

Medication Segment

Pick List

Finalizing and Unfinalizing Documentation


Appbar for Operating Room Nurse/Unit Associate

1. To customize the Appbar, sign in to the Appbar using

Tent Card Username and Password

2. Customize Appbar by selecting the Appbar Icon

3. Add the following applications to the Appbar

a. Powerchart


b. Scheduling Appointment Book

c. Scheduling Reports

d. Surgical Case Check In.

4. Your appbar should look like this


Viewing the Surgery Schedule

We all like to star off our day looking at the surgery

schedule. To view the Surgery Schedule select on the

Scheduling Reports Icon on your Tool bar

1. Click on the Scheduling Reports Icon

2. You will notice several tabs populate

3. To view your schedule, select the LOCATION tab.

4. Complete the following


5. Select View at the bottom of the screen and the

schedule will populate:


Schedule Appointment Book Overview

1. Access the Scheduling Appointment Book on the Tool bar

1. Review the Task Menu: This is where you will change

the password and exit out of the application.

2. Icons of Toolbar: Hover over icons to demonstrate the

hover to discover feature of the program. **Review Help

Menu***

3. Review the Calendar: Demonstrate selecting a date

4. Bookshelf: Demonstrate the Books and Appointment Tabs

5. Work in Progress: This is where the appointment details

appear.

6. Appointment Book: This has the resources and times.


Scheduling a Rapid Appointment

To add a rapid appointment (i.e. emergency procedure or add-

on procedures) you must

1. Access the Scheduling Appointment Book on the Tool bar

2. Complete all required field in the Appointment Tab.

3. Complete the following information

Appointment Type: Surgery Rapid

Appointment Location: Use the drop down menu to select the

appropriate location


Person Name: You the … icon to search for the correct patient

and select the appropriate encounter

Primary Surgeon: You can type in the first few letters of the

surgeon’s name and then you can search for the name or use the

search glass to find the surgeon’s name


Patient Type: Select the patient type from the scroll down list;

select inpatient

Priority: This will automatically default to Emergency

Preoperative Diagnosis: This is a free text field. Type the

Preoperative Diagnosis

When you are completed with the information, select the move

button in the middle of the bookshelf

An order’s window will appear


In the Search box, search for the procedure. Search for

Appendectomy and press enter


Select Appendectomy Laparoscopy by double clicking.

Appendectomy Laparoscopy will move up and required details

will appear on the side.

Complete required fields

PAT Required? Select No from Scroll down

Procedure Code: Search for the diagnosis and select the

appropriate diagnosis

The appointment has moved to the Work in Progress box.

Select the resource and drag it to the open area on the

appointment book from the resource

Or you can select the Schedule button at the right and select the

room, time, and duration of the procedure.


Once the appointment appears on the grid. Right click on the

appointment and confirm request

After confirming request. The encounter review window will

come up and you will review the encounter information. Select

OK.

Exit Appointment book from the exit icon.

You should now see your patient on the Perioperative Tracking

Board.


Surgical Case Check In

The majority of our patients will be checked in by Preop.

Some patients will be checked in by us because the arrive

directly to the Operating Room.

1. Today we will check in both our scheduled patient and

our add on patient. To check in your patient from the

appbar select the Surgical Case Check In App

2. As soon as you open surgical check in you will be

prompted to select your location. Today we will select

the CCB OR.

3. Utilize your Filters on the Right to Check In your

patient by MRN.


4.

Select the checkbox in front of your patient’s name to

check them in

When you are complete with checking in your patient you

can select the x on the top right of the window.


Perioperative Tracking Board

Set Events

Events on the tracking board are captured in the perioperative

documentation and when setting events. Any events that are

reflected from the documentation cannot be changed manually

on the tracking board.

Today, we will set events through our documentation.

Accessing the Patient’s Chart

To access the patient’s chart, find your patient in the CCB OR

tab.

Click on the Triangle to the left of the patient.

You will be at the Nurse View to view the Preop Summary for

your patient.


Locating Documentation and Documenting in PreopCheck list

1. In the document’s component of your nurse view you will

see available documentation for your patient such as a

History and Physical and Clearances. Let’s open the

History and Physical and Three Progress Notes.

2. Now let’s review the Periop Preprocedure Checklist. All

patients that are admitted to Surgery will have this

checklist. All other patients, Inpatient’s will have the

Inpatient Preop Checklist.

3. Open the form and Modify


4. 5. Let’s Select the checklist Component from our table of

contents

You can review what was documented and add

information as necessary.


Let’s Select the Perioperative Protocol from the table of

contents.

You will address each line as applicable. Some features

in this table are if you select the word yes on the top of

the field, it will highlight all field as yes.


After signing the form, you will notice that there is a

modification made to the form and your name stamp

appears


Exit out of the form, refresh, and notice that

Preoperative Checklist component reflects that all

elements have been checked.


Accessing Patient’s Intraoperative Documentation

To access the patient’s intraoperative documenation, right select

the patient’s name from the tracking board and select Open

Patient’s Chart > Perioperative Doc

The documentation selection window will appear, select Intraop

Record

The intraoperative documentation will appear.


Overview of Case Document Manager

Case Document Manager is a Cerner Millennium application

that is used for documenting all phases of patient care within the

surgery and anesthesia environments. Case documentation of a

patient procedure would include the following elements:

Documentation. Document segments let you designate

how sections of a patient record are used for charting a

case. These are built as data-entry forms for ease of

charting.

Pick List. This is the list of all inventory items required for

the specific patient procedure. It can be used for inventory

tracking and billing purposes.


Toolbar in Case Document Manager

The Case Document Manager toolbar contains the following

elements:

Button Action

Open. Opens the Case Select dialog box so you can

select a case.

Save. Saves changes made in the current session.

Print. Opens the Print dialog box for your printer.

Finalize.

Opens the Documentation Deficits window, which

displays the list of documents that require

completion.


Add

Segment.

Opens the Add Segment dialog box so you can

add a segment not included in the selected case

originally.

Times.

Opens the Case Times segment template, which

requires completion before the document can be

finalized.

Verbal

Orders.

Opens the Verbal Orders Review window, in

which you can approve verbal orders associated

with the case.

Report

Shortcut.

Up to five of these buttons could be displayed on

the toolbar. These buttons have been defined in

the Report Builder application so you can generate

reports quickly at the click of a button. Hold your

mouse over the icon to display a tooltip that

indicates the name of the report that will be

generated when you click the button.

View

Signatures.

Opens the Electronic Signatures dialog box so you

can view signed or unsigned items for fields,

segments, or documents.

Sign

Document.

Opens the Electronic Signature box for comments,

if your system is set up to allow comments, or the

HNAM Authorizing dialog box so you can sign

the current document.

Supply

Cabinet

Details

Opens the Supply Cabinet Details window, which

displays information for all items which the

system automatically updated in the case

documentation.


Selecting the Pick List tab activates the following toolbar

elements:

Delete. Removes selected items from the pick list.

Fill.

Decrements inventory for the actual item quantity

that was brought in for the procedure. This usually

equals the total sum of the open and hold quantities.

Use. Indicates the actual item quantity that was used

during a procedure.

Return

Unused.

Changes the entered amount for Return Unused back

to zero for the selected pick list item as the items that

are unused are returned to inventory.


Intraoperative Documentation

Adding a Segment

Use Case Document Manager to add a segment to the list for the

current patient case. Complete the following steps to add a

segment:

1. Click the Documentation tab in the Case Document

Manager window.

2. Click Add Segment or right-click within the segment

list and select Add Segment. The Add Segment dialogue

box opens.


3. Select the segment you want to add from the Available box

and click the arrow button to move the segment to the

Selected box.


1. Click OK to save the entry and exit the dialogue box. The

segment is added to the Documentation box in the Case

Document Manager window.


Discontinuing a Segment

Use Case Document Manager to discontinue a segment that has

been added to the list previously. Complete the following steps

to discontinue a segment:

1. Select the Documentation tab in the Case Document

Manager window. The list of segment names for the

selected case is displayed.

2. Right-click the segment name and select Discontinue

(Segment Name) from the context menu.


The segment now is unavailable for charting, and an

Unavailable icon ( ) is displayed beside its name on the

segment list.


3. If prompted to give a reason for discontinuing a segment,

select a reason for discontinuing the segment and click OK.

Note

You cannot discontinue required segments.


Reactivating Discontinued Segments

Use Case Document Manager to reactivate a discontinued

segment. Complete the following steps to reactivate a segment:




2. Right-click the name of the discontinued segment and

select Activate (Segment Name).

The segment is activated and available for charting.


Terminating a Document

Case Document Manager lets you terminate the documentation

process if an event occurs that makes continuation of that

document no longer needed. Complete the following steps to

terminate a document:


Manager window. From the Document menu, select

Terminate to open the Terminate Document dialogue box.


2. Select from the list the reason for terminating the

document.

3. Indicate whether charges should be sent or postponed for

this document.


4. Click OK to terminate the document and exit the dialogue

box.

Completing a Segment

In the Case Document Manager window, you are able to enter

information associated with the selected segment. In order to

complete a segment, perform the following steps:


1. Select the Documentation tab in the Case Document



2. Segments with the red exclamation point are considered

required segments. Elements must be addressed in each

segment.

3. Select the segment to be completed; the template form

associated with that segment is displayed on the right side

of the window. The format varies according to the type of

data to be entered, such as check boxes, text entry, or lists

from which to select.

4. Enter information as appropriate in the displayed fields.

o As you are completing the template form, the

following buttons are displayed for your use:

<<Prev Returns you to the previous segment or

segment page.


Next>> Advances you to the next segment or segment

page.

o Note

o Many template forms are more than one page in

length. The page number associated with the displayed

page is shown in the lower left corner of the Case

Document Manager window. Use the <<Prev and

Next>> buttons to display a different page.

o When the segment contains a list box, the following

additional buttons are displayed for your use:

Add Adds the data entered into the fields to the

list box.

Modify

Once you have highlighted a row of existing

data in the list box, the data populates the

respective fields in the segment. You can

change the information as needed, then click

Modify to update the list box.

Remove

Deletes a selected row of data from the list

box. The message, Delete current entry? is

displayed. Click Yes or No.

Clear Clears any data entered in the fields.

5. If you must electronically sign the segment, select Task

menu > Sign a Case.


Documenting in Segments

Anatomy of a Segment

Each segment has several types of field. Date and Time fields

(i.e. Case Time Segment) can be documented by select the time

icon or free text. You can use the shortcut of N for now.

Some segments have tables such as the counts and procedure

segments.


PNDS- Perioperative Nurse Date Set (Care Plans)

The Perioperative Nursing Data Set (PNDS) was developed and is

maintained by the Association of Perioperative Registered

Nurses (AORN). PNDS is a standardized perioperative nursing

vocabulary that describes diagnoses, interventions, and patient

outcomes.

Some segments contain PNDS outcomes. For example the

Counts Verification Segment.

This is indicated by the outcome met at the bottom of the

segment.

You can right free text notes in each segment. This can be

used to elaborate and nurse’s notes.


Cultures and Specimens

1. Place order and click sign. Select order for multiple

specimens to make documentation quicker if another

specimen is added

2. Place Pathology multipart collection PowerPlan

3. Order in a Ordered/dispatched status

a. Select Specimen Collection Icon on Toolbar

b. Scan patient arm band for PPID (Override option

available to the OR)

c. Select Print Label icon

3. Uncheck orders not to print

a. Select printer if not defaulted

b. Select Print

c. Place label on container

d. Scan label to mark as collected


e. Select sign to save and close

Implant/Tissue Log Segment

1. Select the implant or tissue log segment

2. Scan the item into the Barcode Scan- Use Mode window

to populate the implant details. Add additional

information if required.

4. If implants cannot be scanned, manually, enter implants to

implant log form and implant history control.

Medication Segment

To document medication administration use the scan icon on the

tool bar, scan the medication label. Document volume and

time given within the segment details.


Pick List

Updating Pick List Items from Documentation

You can update pick list items during documentation. You do

not have to open the Pick List tab to update the pick list.

1. Complete the segment and click Prev or Next to open the

Pick List Update Confirmation dialogue box.

The Item Information section contains the name and

number of the item, along with an option to indicate

whether you want to include the item in the pick list update.

Various indicators are displayed adjacent to the item

https://wiki.ucern.com/x/axk4Sw


depending on the change the item has on the pick list.

These indicators are as follows:

Indicator Pick List Modification

(yellow circle) This indicates the item is new to the

pick list.

(green up

arrow)

This indicates you are increasing the

used quantity for this item.

(green down

arrow)

This indicates you are decreasing the

used quantity for this item.

(blue up arrow

with line)

This indicates you are exceeding the fill

quantity for the item.

2. Click OK to update the pick list with your changes.


Viewing Pick List Information

Use the Properties command to view information about a pick

list item. Complete the following steps to view pick list item

information:

1. Select the Pick List tab in the Case Document Manager

window to display a pick list tree of inventory items for the

selected case. The Pick List box opens on the right,

displaying a detailed list of the items and could display the

following information:

o The column represents the type of inventory item.

The icons that could be displayed in this column are:

A consumable item.

Reusable equipment that is schedulable.

Sets or packs. Double-click the row to display

the components.

o The Description column displays a description of the

inventory item.


Note

Right-click and choose Properties to view more

detailed information about the selected item.

o The Item Number column indicates the inventory

item number.

o The column indicates that duplicate items exist.

o The Open Qty column indicates how many of the

current item should be opened and ready to use. This

value can be modified by clicking on the number, then

typing the new value.

o The Hold Qty column indicates how many to have on

hand, closed and sterile. This value can be modified

by clicking on the number, then typing the new value.

o The Fill Qty column indicates how many items are to

be filled.

o The Used Qty column indicates how many items were

used.

o The Wasted Qty column indicates how many items

were wasted.

o The Return Qty column indicates how many items

are to be returned.

2. Right-click a pick list item and select Properties from the

context menu to open a corresponding Properties dialogue

box.


3. Select the General tab to view descriptive information,

such as the item number, package type, or class. Click the

Specifics tab to view such details as open or hold

quantities, fill location, or cost.


4. Click OK to close the dialogue box.

Adding Pick List Items

Adding Pick List Items

Use Periop Doc to quickly add items to a pick list. There are two

methods for adding pick list items. You can add items by using

the Pick List tab or directly from documentation.

The fist time you work with a Pick List, you will need to set

your defaults. After this, your defaults will automatically

populate each time you log on. To set your defaults with SSH

recommendations:


1. Click the Pick List tab in the Periop Doc window to

display a tree of inventory items for the selected case. The

Pick List box opens on the right, displaying a detailed list

of the items.

2. Right-click anywhere in the Pick List screen and select

Options.

3. Select the Advanced tab.

4. Change the Open Qty to 1.


5. Ensure the second two options, Default Used = Fill Qty and

Charge Qty = Used Qty, are both selected.

6. Click OK.

Complete the following steps to add pick list items using the

Pick List tab:

1. Locate the inventory item to be added to the pick list by

entering the name or partial name of the item in the (Item)

box. If you are unsure of the name of the item, press the

small ellipsis button to open the Find: All Items dialog box,

in which you can enter specific information to narrow your

search.


If you enter a partial name, then press ENTER, and the

dialog box expands. Select the appropriate item, then click

OK to return to the Pick List tab.


2. Select the item you want and click OK to return to the Pick

List window. Your selection is displayed in the Item box.


3. Click Add. The item is added to the pick list. Repeat these

steps to add more items; adjust the item quantity as needed.

4. Click the save button ( ) to save your entry.

=


Removing Pick List Items

Removing Pick List Items

Complete the following steps to remove a pick list item:

1. Select the Pick List tab in the Periop Doc window to

display a tree of inventory items for the selected case. You

can select a classification folder from the tree to see only

items for that class, such as Catheters or Gloves. The Pick

List box opens on the right, displaying a detailed list of the

items.

2. Select the pick list item to delete and click or right-click

the pick list item and select Delete.


3. The following confirmation message is displayed: Are you

sure you want to delete the item? Click Yes to remove

the item from the pick list.

4. Repeat these steps to remove more items from the pick list

if needed.

5. Click the save button ( ) to save your changes and

update the pick list.


Charting Pick List Fill Quantities

Charting Pick List Fill Quantities

Use Periop Doc to document the pick list item quantities that are

brought in for a patient procedure. Complete the following steps

to chart fill quantities for pick list items:

1. Select the Pick List tab in the Periop Doc window. The

Pick List box opens on the right, displaying a detailed list

of the items.


2. Right-click anywhere in the Pick List window and select

All. The selected items will turn blue.

3. Click Fill from the toolbar. All items are now filled.

4. Select Used . All items are now documented as used.

5. Document by exception o complete the documentation.

6. You can also document fill (and used) items individually.

Select the pick list item to fill and click or right-click the

pick list item and select Fill.


The system automatically enters the total of the Open and

Hold Qty columns in the Fill Qty column. You can enter a

different quantity in the Fill column manually; however,

you must clear values, such as Charge Qty and Used Qty,

in the correct order before changing the Fill Qty.

7. Click to save your entries.


Note: Once the record is saved and finalised, all used items will

cross to SAP. Inventory will be reviewed here and supplies

reordered based on information in SAP.

Charting Pick List Used Quantities

Charting Pick List Used Quantities

Use Periop Doc to document the pick list item quantities that are

used in a patient case. Complete the following steps to chart

used quantities for pick list items:

1. Select the Pick List tab in the Periop Document window.

The Pick List box opens on the right, displaying a detailed

list of the items.

2. Select the pick list item to use and click or right-click

the pick list item and select Use.


The system updates the Use column with the same quantity

as the Fill column.

Note

You can enter a different Used Qty manually; however, the

system prompts you if that quantity exceeds the Fill

Quantity and asks if you want to fill from another item. If


you select Yes, the system adjusts the Fill Qty to match the

new Used Qty.


Note: Once the record is saved and finalised, all used items will

cross to SAP. Inventory will be reviewed here and supplies

reordered based on information in SAP.


Adding Pick List Comments

Adding Pick List Comments

Complete the following steps to add comments to a patient

document:

1. With a patient case selected in the Periop Doc window,

scroll through the (Comment Type) list in the lower portion

of the right side of the window.

2. Select the comment type to which a comment is to be

added.

3. Enter your comments in the (Comment) box.



Finalizing and Unfinalizing Documentation

Finalizing the Document

Use Periop Doc to finalize a document when you have finished

charting a patient case. The Finalize function checks to ensure

that all required documentation is complete before continuing.

Complete the following steps to finalize a document:

1. Click the Documentation tab in the Periop Doc window.

From the Document menu, select Finalize or click on

the toolbar.

2. The system checks for document deficits with one of the

following results:

o If all required documentation is complete, the system

displays the message, The document has no deficits.

Would you like to finalize the document? Click Yes.

o If incomplete required documentation remains, the

Documentation Deficits dialogue box opens.

3. Once finalized, the finalized documentation is displayed.


Complete the following steps to unfinalize a document:

1. From the Document menu, select Unfinalize or click in

the toolbar.


2. The Unfinalise Reason dialogue box is displayed. Select a

reason from the list.

3. Enter a comment if needed and click OK.

The document is now unfinalised.


Case/Procedure Cancelled During Intraop/Intraprodure

1. If patient did not enter the operating room/procedure room

and procedure supplies are not opened. You must complete

the following steps

a. Open Periop Doc from the table of contents

b. Select Document from the toolbar and select

Terminate

c. Select appropriate termination reason


Select option to postpone charges.

2. If the patient did not enter the operating room /procedure

room and supplies were open.

a. Open pick list and reflect open supplies and return

unopened supplies. Save Charges.

b. Select Document from the toolbar and select

Terminate


c. Select appropriate termination reason


Select termination reason, and select send charges for

this document and Check off Pick List Charges.

3. If case cancelled after patient entered the room before/after

anesthesia complete the following steps.

a. Open Periop Doc from the table of contents.

b. Add Case Cancelled Segment from Available table

and moved to selected table. Select OK.


c. Document required fields in Case Cancelled Segment


d. In Case time segments document the following:

i. In Room Time: Time you went in the room

ii. Start Time: Time procedure was cancelled.

iii. Stop Time: Time left out of the room

iv. Out of Room Time: Time left out of the room

e. Document on segments that activities were preformed.

i. Case Attendees

ii. If Foley was inserted: Catheters Segment

iii. Transport Segment

f. Discontinue Segments that do not contain

documentation. To discontinue component. Select

the component, right click and select discontinue

component.

the day in the life of the or nurse · 7/18/2018 · accessing the patient’s chart to access the...

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