Anesthesia Review Notes



1. Access Citrix Web Access: Double click on the desktop icon or enter “ekids” in the KDnet url.

a. This action will display the Citrix Log in screen.

2. Enter your network User name and Password. This is the same as your email log in information.

3. Select the eKiDs SurgiNet or PowerChart icon. This action will display the application Log In screen.

[pic][pic]

4. Log in by entering your application (PowerChart or SurgiNet) User Name and Password.

5. Click in the Patient Search field to enter search criteria to launch the look up activity. You can also launch the Patient Search activity from the Patient Menu.

6. Look up the patient by entering the search criteria and selecting the target patient. The primary search criteria for looking up a patient in SurgiNet is 3,3 i.e., first three letters of the lastname, first three letters of the firstname. You can also look the patient up by medical record number by entering MRN in the designated field.

Important Notes:

• Anesthesia Pre-Op Review Notes should be applied to the Pre-Admit Testing visit encounter

o The Medical Service should be Pediatric Surgery

o The Registration Date should be listed as a “Future” date that matches the date of the surgery.

o You can change the encounter from the opened chart by selecting the Encounter hyperlink.

7. Once you have located the correct visit encounter, click OK to open the patient’s chart.

8. Click on the Documents tab to enter the Anesthesia Pre-Op Review note.

9. Click on the Documents tab and select the Add Document button on the toolbar to open the new note form.

10. Complete the required fields before entering review note text. This form has a required field for “Type”; can be set to default into the form. Click on the down arrow to select the only option. The Review Note text is entered in the white section of the form. You may paste notes into this form if you have specific saved text you would like to enter on a routine basis.

|Field |Description |

|Type |Click the down arrow to select the available form; KD Anesthesia Preop Review. Instructions to set |

| |this form to automatically default in each time is located on the last page of this document. |

|Author |The name of the user logged in will default in this field. |

|Date |The current date and time will default in but may be adjusted if applicable. |

|Status |A view only field that will default to In Progress until the form is Signed. |

|Subject |This is an optional field. Text entered here will display as the Result Title in the saved and |

| |signed document. |

New Note Button Options

11. Select the button option to Save, Sign or Cancel the entered note.

|Button Option |Action Description |

|Sign |When selected, changes the form status to Auth (Verified). |

|Save |When selected, does not change the form status of In Progress. The form will appear in documents tab visible only to|

| |the author. The form dialog box remains open. |

| |You may close the save note by clicking on the X in the upper right corner of the form. |

|Save and Close |When selected, does not change the form status of In Progress. The form will appear in documents tab visible only to|

| |the author. The form dialog box closes; you will prompted the view the newly created document. |

|Cancel |Will allow you to exit the form without committing your changes. |

Important Notes:

• You can edit and sign a Saved document by selecting the Modify button when the form is open or by right clicking on the open form and selecting the Modify option.

• When Message Center is implemented, Saved documents will appear in the Work Items section as a saved document awaiting completion and signature.

• If a Pre-Op Anesthesia Note has been entered on the wrong patient, you must notify Medical Records to “In Error” the document.

Modifying a Document

You can make edits if necessary after the document has been signed by selecting the option to Modify from the Documents tab. Modification to signed documents is added as an addendum to the original note.

Steps to Modify a Signed Document:

1. Open a target patient’s chart

2. Select the Documents tab

3. Expand the Documents folder to locate the document you want to modify

4. Click on the document you want to modify

5. With the document open, right click and select the Modify option or click on the Modify button on the toolbar [pic].

6. Add additional notes in the area designated *Insert Addendum Here:

7. Click the Update button submit the modified note

Notes:

• Once a note has been modified displays the below text in red on the note.

• The color of the document in the folder tree will appear purple to reflect that the form has been modified.

Viewing Documents

By clicking the radio button located at the left corner of the screen, you can sort the available documents to streamline viewing.

|Sort Option |Sort Description |

|By Type |This option allows you to sort the display by the form |

| |type, i.e., Consult Notes, OP Report. |

| |The Anesthesia Pre-Op Review note will display under |

| |folder heading of: |

| |CHKD – Inpt, ED, DS, Therapy in the KD Procedures |

| |subfolder |

|By Status |This option allows you to sort the display by the form |

| |status, i.e., In Progress, Auth (Verified) or In Error. |

|By Date |This option allows you to sort the display by the date the|

| |form was entered. |

|Performed By |This option allows you to sort the display by the name of |

| |the person that entered the form {pictured to the left}. |

|By Encounter |This option allows you to sort the display by encounter |

| |dates. When selected, will display all documents |

| |associated with a specific encounter. |

Tip: when selecting “your” items from the documents tab, change the sort option to Performed by, this will help you quickly identify documents for viewing or modification.

Color Legend

When you are viewing patient reports from the Documents tab, you will notice a color associated with each document. To display the color legend, click on Index from the main menu and select the Color Legend option.

|Color |Document Status |

|Pink |These documents have been saved, but not signed. |

|Dark Green |This is a transcribed document |

|Turquoise |This is an Unauthenticated document. |

|Light Red |A document that has been signed, has the status of AUTH (Verified). |

|Purple |A document that has been modified after it was signed. |

|Red with an X | |

|Dark Blue |An anticipated document, at CHKDHS the only anticipated document you will see in the folder is |

| |an Op Report. |

Toolbar Options

| |Set text color |

| |Enlarges displayed document |

| |Decreases the size of the displayed document |

| |Cuts highlighted text. |

| |Copy to clipboard |

| |Paste from clipboard |

| |Clear uncommitted text |

| |Bolds highlighted text |

| |Underlines highlighted text |

| |Italicizes highlighted text |

| |Strike through text – This feature is not an available for use. |

| |Left justifies text |

| |Centers text |

| |Right justifies text |

| |Insert Template – This feature should not be selected for use. |

| |Manage Auto text – This feature is not available for use. |

Setting a Default Form

You can set a form to default in each time you select the option to add a review note. When a default is set, you can begin completing your review note immediately.

Steps to Set a Default Form:

1. Open a patient’s chart

2. Select the Documents tab

3. Click on Documents button on the toolbar

4. Select Options

5. Click the down arrow on the Default Document Type field

6. Select the KD Anesthesia Preop Review from the selection list

7. Click OK to save you selection

-----------------------

Information Services Education Department

Children's Hospital of The King's Daughters

01/30/2010

2010

Once the option is elected to create a new note, the blank form will display to free text entry. Click on the white space of the displayed form to type your pre-op review notes. You can format the text by clicking on the toolbar button to bold, underline, as well as change the color of the text.

Patients matching the entered search criteria will display in the top portion of the Patient Search window.

The bottom section displays the visit encounters for the highlighted patient. Remember; select the Pre-Admit Testing visit encounter.

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

Anesthesia Review Notes

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

[pic]

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download