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Appendix. EPIC Smart Texts available to complete faculty documentation of anesthesia care (6/1/13)Note. Not a complete list of all possible documentation Smart Texts. Additional Smart Texts available for care provided in the ICU, in Pain Management Clinic, on the Acute Pain Service, and Pain Procedures. Surgical AnesthesiaDocumentationSMART TEXTDescriptionPreoperative Evaluation and PlanANS FACULTY PRE OP NOTEComplete note. Refers to preoperative evaluation done over phone (preop clinic) or on the floor as inpatient by resident..PREOPADDENDUMSmart phrase (aka “dot phrase”). Addendum to preoperative evaluation done over phone or on the floor. ANS PRE-OPERATIVE INPATIENT EVALUATIONUsed when doing initial INPATIENT evaluation. Note. Additional documentation needed by faculty to meet hospital documentation requirements (found in “ANS FACULTY PRE OP NOTE” or “.PREOPADDENDUM”ANS PRE-OPERATIVE TELEPHONE EVALUATIONUsed when doing initial TELEPHONE evaluation. Note. Additional documentation needed by faculty on day of surgery to meet hospital documentation requirements (found in “ANS FACULTY PRE OP NOTE” or “.PREOPADDENDUM”ANS PRE-OPERATIVE TELEPHONE EVALUATION VLUsed for VL patients when doing initial TELEPHONE evaluation. Note. Additional documentation needed by faculty on day of surgery to meet hospital documentation requirements (found in “ANS FACULTY PRE OP NOTE” or “.PREOPADDENDUM”InductionANS INDUCTIONNon specific note that meets billing documentationANS INDUCTION ETTSpecific for IV induction and intubationANS INDUCTION LMASpecific for IV induction and LMA placementANS INDUCTION MACNote for the beginning of MAC caseANS INDUCTION TIVASpecific for TIVA induction without airway applianceIntraoperative monitoringANS INTRAOP VSSNon specific note for documenting that the faculty has come into the room and checked on the patientTransferANS TRANSFER NOTEUsed when transferring care to another facultyAcceptANS ACCEPT NOTEUsed when accepting care from another facultyEmergenceANS EMERGENCENon specific note that meets billing documentationANS EMERGENCE ETTSpecific for faculty present during extubationANS EMERGENCE LMA AWAKESpecific for faculty present for removal of LMA awakeANS EMERGENCE LMA DEEPSpecific for faculty present for removal of LMA deepPostoperativeANS POST OPERATIVE FACULTYFor all patients except MAC patients going back to holding. Meets both billing and hospital requirementsANS MAC FACULTY POST-OPFor MAC patients going back to holding. Meets both billing and hospital requirementsObstetric AnesthesiaDocumentationSMART TEXTDescriptionPreoperative Evaluation and PlanANS OB ANESTHESIOLOGY PREOPERATIVE REVIEWComplete note. Can be used if no other preoperative note is in EPICANS OB FACULTY PREOP CS ADDENDUMFor c-section or other surgical procedures. Addendum to preoperative evaluation done by resident. ANS OB FACULTY PREOP LEA ADDENDUMFor labor analgesia. Addendum to preoperative evaluation done by resident. Induction c-section or other surgical proceduresANS OB CS INTRAOPERATIVEInduction note for c-section. Intra-partum ANS OB LEA INTRAPARTUMOngoing labor analgesia noteANS INTRAOP VSSOngoing surgical anesthesia. Non-specific note. PostoperativeANS POST OPERATIVE FACULTYFor all patients, meets both billing and hospital requirements. ................
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