sims preop manager pre-operative evaluation rn training...

SIMS PREOP MANAGER

PRE-OPERATIVE EVALUATION

MD TRAINING MANUAL

© 2009 The Ottawa Hospital

SIMS Preop ManagerPre-Operative Evaluation

MD Training Manual

T A B L E O F C O N T E N T S

SIMS PREOP MANAGER.................................................................................................I PRE-OPERATIVE EVALUATION.....................................................................................I RN TRAINING MANUAL...................................................................................................I TABLE OF CONTENTS...................................................................................................II1 INTRODUCTION ............................................................................................................ 1 1.1 Learning Objectives ..................................................................................................... 1 1.2 Navigation: Getting Around the System ...................................................................... 1 1.2.1 Menus and Commands ............................................................................................ 1 1.2.2 Tool Bar .................................................................................................................... 2 1.3 Changing Your Password ............................................................................................ 3 1.4 Changing Users ........................................................................................................... 5 1.5 Glossary of Terms ...................................................................................................... 6 2 SYSTEM OVERVIEW ..................................................................................................... 8 2.1 Census List .................................................................................................................. 8 2.1.1 Census List Types .................................................................................................... 9 2.2 Quick Menu .................................................................................................................. 9 2.2.1 Patient Identification ............................................................................................... 11 2.2.2 Adm Ht/Wt/BSA/BMI/Blood Type ........................................................................... 12 2.2.3 Allergies and Precautions ....................................................................................... 13 2.2.4 Current Medications ............................................................................................... 16 2.2.5 Nursing Health Assessment/Vital Signs ................................................................. 17 2.2.6 Surgical History ....................................................................................................... 18 Nursing Preoperative Plan of Care ................................................................................. 19 2.2.7 Preop Instructions ................................................................................................... 20 2.2.8 MD Assessment ..................................................................................................... 21 2.2.9 Anesthesia Plan ...................................................................................................... 25 2.2.10 Tests and Results ................................................................................................. 28 2.2.11 Record Status ....................................................................................................... 29 2.2.12 Signatures ............................................................................................................. 30 2.2.13 Addenda ............................................................................................................... 31 2.2.14 Copy Forward ....................................................................................................... 32 3 HANDS-ON EXERCISES ............................................................................................. 33 3.1 Getting Started ........................................................................................................... 33 3.2 Record Status Workflow ............................................................................................ 35 3.3 Searching For a Patient ............................................................................................. 37

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MD Training Manual3.3.1 Searching For a Patient by MRN ............................................................................ 37 3.3.2 Searching For a Patient by Last Name .................................................................. 39 3.3.3 Searching for a Patient by Today’s Visits ............................................................... 41 3.4 Documenting a Patient ............................................................................................. 43 3.4.1 Simple Complexity Case Scenario ......................................................................... 43 3.4.2 Intermediate Complexity Case Scenario ................................................................ 57 3.5 Self Study Scenario ................................................................................................... 82


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MD Training Manual

1 INTRODUCTION

This document provides hands-on practice scenarios that take the learner through the basic flow of a MD using SIMS Preop Manager in the PAU. The scenarios illustrate key functions of the system and supporting workflow changes; they are not intended to detail each screen/field in the system. The training materials are also intended to be generic so they we can re-use them from Campus-to-Campus.

1.1 Learning Objectives

By the end of the session, you will be able to:

• Logon and Logoff of SIMS Preop Manager• Find the proper patient using the census list• Find the proper patient using the search feature• Document assessment of the patient

1.2 Navigation: Getting Around the System

1.2.1 Menus and Commands

The menu is a table of contents for the application commands that can be performed.


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MD Training ManualCommands are specific tasks that will be performed when they are clicked on and are accessed from the menu.

1.2.2 Tool Bar

A toolbar provides easy access to the most commonly used functions in the application.


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1.3 Changing Your Password

When you launch SIMS Preop Manager, the CareSuite Logon screen is displayed.

All users will be given a logon (user name) and password. At this point, you will create your own unique password.

To change your password:

1. Click Change Password….

The Change Password screen is displayed.


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MD Training Manual2. Type your user name in the User Id field.

Note: The User Id field on the Change Password screen and the User Name field on the CareSuite Logon screen represent the same field.

3. Type your current password in the Password field.

4. Type your new password in the New Password field.

5. Type your new password again in the Confirm Password field.

6. Click OK.

The CareSuite Logon screen is displayed.

The SIMS system will prompt you to change your password at a specified interval similar to the hospital network. It is recommended that when you change your network login credentials, you do the same for the SIMS software. That way, prompts for password changes will stay in sync with one another.


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1.4 Changing Users

To log off the current user:

1. Select File Log off from the File menu.

The CareSuite Logon screen is displayed.

To logon as a new user:

2. Type your user name in the User Name field.

3. Type your password in the Password field.

4. Click OK.

Note: After changing users, the screen displayed will be the same one that was being accessed when the previous user was logged off.


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1.5 Glossary of Terms

TERM / ACRONYM DEFINITIONAnaesthesia Manager An electronic patient charting module within the Picis Application which

allows anaesthesia to view and document on device data, demographics, events, medications, fluids, lab results and patient care provisions. This module may also be used for some nursing documentation (i.e. in SDA or SDCU preoperatively).

Booking Bookings are created in OR Manager by the OR upon receipt of an RFA.

Case Record Case Records are created in OR Manager by the OR. All OR Nursing documentation is captured on the case record. Data from the case record can be pre-populated by data from pre-op manager and data from the case record can flow through to Anaesthesia Manager.

EHR Periops Record ofOperation

The Perioperative record of operation is the document that records the surgical encounter in the OR. Listing the start and stop times of the surgical case, surgeons, anaesthetists, and other staff in the operating room and the actual procedure done. This record is currently printed via the OR Manager system and will be available in vOacis for viewing effective March 2009.

OR Manager The electronic system used to book surgical cases in the operating room. OR booking will start upon receipt of the Request for Admission. Data entered includes surgeon, surgical procedure, anaesthesia alerts, equipment needs etc. The system will perform conflict-checking of equipment, prepare preference cards and pick lists. Data regarding equipment is sent automatically to Logistical Services to build case carts.Elective OR lists are printed from OR Manager.

PACU Manager An electronic patient charting module within the SIMS project which allows nursing staff to view and document on device data, demographics, events, medications, fluids, lab results and patient care provisions within the PACU. This module may also be used for some nursing documentation in SDCU (i.e. Phase II documentation).

Patient Specific Data All data captured and stored in the system pertaining to a patient, such as clinical assessments, medications, insurance information etc.


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MD Training ManualTERM / ACRONYM DEFINITIONPicis Picis is the vendor which was selected by TOH after an extensive RFP

process to provide perioperative software solutions. The Picis modules purchased by TOH include: Preop Manager, OR Manager, Anaesthesia Manager and PACU Manager.

Preop Manager A system which allows for the creation of an electronic pre-anaesthesia evaluation. The clinician can sign off an evaluation to indicate the patient is ready for surgery. This can be viewed before, during or after surgery. Some of the information from here will populate into Anaesthesia Manager and PACU Manger.

RFA Request for Admission. This is the paper document that currently comes from the surgeon’s office to request a booking of OR time for surgical procedures. This is the document that begins the OR booking process.

SIMS SIMS stands for Surgical Information Management System and is the name given to this project.

Smartrack A patient tracking module that comes with the Picis application. It is an interactive tool that is used to track the status and location of patients throughout their Perioperative visit. Smartrack screens can be accessed on any computer that has OR manager installed. LCD displays are installed in Perioperative areas t provide a visual display of OR activity.

WTIS Wait Time Information System - provincial system that TOH reports to that tracks how long patients have been waiting for surgery.


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2 SYSTEM OVERVIEW

The following section outlines the different SIMS Preop Manager screens that a MD may need to access in order to perform a pre-operative evaluation. Familiarizing yourself with the specific Quick Menus (2.2) will help in finding relevant patient information. When Anesthesia Manager is launched in 2010, it will be incumbent on the Anesthesiologist to document this information for in-patients/emergency patients.

2.1 Census List

After successfully logging on to SIMS Preop Manager, the Census List screen will be displayed.

The purpose of the Census List screen is to provide users with a tool to find patients in the system using different search criteria (e.g., by today`s visits, by MRN, by last name).

Census lists are Campus (and location) specific. The default view will be your current location. For example, if you are working at a Riverside ECC (Eye Care Center) workstation, “ECC-Preop Patients-Scheduled for Today” will be your default view. However, you should have access to all census types in the pull-down menu.


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2.1.1 Census List Types

Pre-Op Patients – Scheduled for Today: This is a list of all patients who are scheduled for the PAU clinic for today.

Pre-Op Patients – Scheduled for Tomorrow: This is a list of all patients who are scheduled for the PAU clinic for tomorrow.

Pre-Op Patients – Scheduled for 1 Week: This is a list of all patients who are scheduled for the PAU clinic for the next 7 days.

Surgery Patients – Today: This is a list of all patients who are scheduled for a surgical procedure in the OR today.

Outstanding Lab/Diagnostic Test Results: This is a list of all patients who have outstanding lab or diagnostic test results.

Outstanding Consults: This is a list of all patients who have an outstanding consult visit or consult report.

Outstanding Follow-up Calls: This is a list of patients who need to have follow-up calls completed. An example would be a call to the surgeon’s office.

Outstanding Records: This is a list of patients that need additional records added to their chart. An example would be an old chart from another hospital.

Pending Anesthesia Review: This is a list of patients that need to have their charts reviewed by Anesthesia.

Ready for Surgery: This is a list of patients whose charts are complete and they are ready for their surgery.

Anesthesia Review Complete: This is a list of patients that have had their charts reviewed by Anesthesia.

On Call Resident Assess – Pending Staff Review: This is a list of patients who have been assessed by the Anesthesia Resident and need to have their charts reviewed by the Staff Anesthesiologist.

2.2 Quick Menu

Selecting a patient from the Census List screen will display the Patient Summary screen. The Quick Menu is displayed on the left side of the Patient Summary screen.


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The font colour will change from white to yellow once information has been entered into the respective menu.

The following sections contain an overview of the Quick Menu options that will be accessed during a patient’s pre-operative evaluation.


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2.2.1 Patient Identification

Selecting the Patient Identification option from the Quick Menu will display the Patient Identification screen.

The purpose of the Patient Identification screen is to:

• Confirm the identity of the patient;

• Capture the patient’s family physician information; and


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2.2.2 Adm Ht/Wt/BSA/BMI/Blood Type

Selecting the Adm Ht/Wt/BSA/BMI/Blood Type option from the Quick Menu will display the Adm Ht/Wt/BSA/BMI/Blood Type screen.

The purpose of the Adm Ht/Wt/BSA/BMI/Blood Type screen is to capture the Assessment Type along with the height, weight and blood type of the patient.

The Assessment Type will be transferred to the top of the customized printed record.

Note: Height and weight values entered are automatically converted to the other units of measure. The patient’s BMI is automatically calculated using the entered information and is displayed in the Patient Summary screen.


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2.2.3 Allergies and Precautions

Selecting the Allergies and Precautions option from the Quick Menu will display the Allergies and Precautions screen.

The purpose of the Allergies and Precautions screen is to capture a patient’s medication allergies, other allergies and precautions.


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MD Training ManualAt present, anesthesia and nursing share the paper record, “PAU Alerts”.

It is the responsibility of both parties to fill the form as required.

In the electronic environment, this will still be the case.

The screen shots below document all the “precautions” that can be captured and that are patient specific (the precaution usually remains the same from one encounter to the next).


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The highlighted descriptors are those that are currently found on the paper record.

Encounter specific issues(precaution is specific to the current surgical procedure) such as postoperative critical care, potentially difficult airway, medically complex patient will be found under “Alerts” in the Anesthesia Plan.


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2.2.4 Current Medications

Selecting the Current Medications option from the Quick Menu will display the Current Medications screen.

The purpose of the Current Medications screen is to capture a patient’s current medication information.

Currently, only SDCU patients will have medications entered electronically. For SDA patients, “see medication reconciliation sheet” will be displayed.


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2.2.5 Nursing Health Assessment/Vital Signs

Selecting the Nursing Health Assessment/Vital Signs option from the Quick Menu will display the Nursing Health Assessment/Vital Signs screen.

The purpose of the Nursing Health Assessment/Vital Signs screen is to:

• Capture the patient’s baseline vital signs;

• Document the patient’s medical history by body system; and

• Document the patient’s social information (SDA).

The nursing assessment will replace Form 71A (Patient Admission History) recently introduced to the PAU and used for all SDA and in-patients.


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2.2.6 Surgical History

Selecting the Surgical History option from the Quick Menu will display the Surgical History screen.

The purpose of the Surgical History screen is to capture the patient’s past surgical history information.

The past surgical history pull down list is populated from OR Manager. As you may imagine, there are a vast number of procedures in the database and it could be very difficult for the nurse or physician to accurately document the exact procedure performed. As a result, it was decided to include a list of about 200 generic procedures. Many of these are designated with the prefix, “Pre-op”.

Line 2 above reads “Pre-op Amputations” and the comment field notes “Right below knee”.

Line 3 above shows just a portion of the generic procedures as searched by the term “pre”. In this case, “Pre-op Bypass Surgery” refers to the fact that a CABG or a PCI may have been done in the past. The details should appear in the “Comments” box.


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Nursing Preoperative Plan of Care

Selecting the Nursing Preoperative Plan of Care option from the Quick Menu will display the Nursing Preoperative Plan of Care screen.

The purpose of the Nursing Preoperative Plan of Care screen is to capture the patient specific pre-operative plan of care.

Relevant items to the physician found in this section may include “Pre-op prescription confirmed”, “confirm medication stopped”, “CPAP machine confirmed”, “Pre-op thrombosis appointment confirmed”, “consult requested”.


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2.2.7 Preop Instructions

Selecting the Preop Instructions option from the Quick Menu will display the Preop Instructions screen.

The purpose of the Preop Instructions screen is to:

• Document surgery specific Preop patient instructions; and

• Document teaching materials provided to the patient.


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2.2.8 MD Assessment

Selecting the MD Assessment option from the Quick Menu will display the MD Assessment screen.

This is where you will find 22 submenus with descriptors related to the anesthetic history, individual body systems, social habits, pain history and physical exam.


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MD Training Manual We strongly encourage the physician to complete the following sections on all patients regardless of status:

• RoS-Anes Hx• RoS-Cardiovascular 1• RoS-Respiratory• PE-Airway• PE-CVS• PE-Resp

It is very important that you review the descriptors contained in the submenus to familiarize yourself with the location of said descriptor. As best as possible, we have tried to create a logical structure to our Review of Systems and Physical Exam. The screen real estate is limited and you will be forced to scroll down through the list to see all entries. More common descriptors will be closer to the top of both the “normal” and “abnormal” finding boxes.

HEADERS

In addition, we have used CAPS to create headers which separate a particular body system into subsections.

For example, all descriptors related to –HYPERTENSION—are listed below the main descriptor. Unfortunately, we cannot stop the software from placing a checkbox beside these headers. We would prefer that these headers not be checked but rather the relevant descriptors that fall below the header.


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+ SIGNS

+ signs signify descriptors that relate to the parent above. This was done as the software does not allow indentation). In the example below, all the descriptors with + signs refer to the complications that one may find with the parent, Diabetes Mellitus - type 1 or Diabetes Mellitus – type 2.

INFO TIPS

These are found exclusively in the RoS (Review of Systems) – Rad-Oncology


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These “info tips” are meant to highlight potential issues related to the respective treatment. They are not meant to be ticked off.


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2.2.9 Anesthesia Plan

The purpose of the Anesthesia Plan screen is to:

• Document the ASA status of the patient;

• Document the “Anesthesia technique discussed”. Boxes under Anesthesia technique “plan” would be reserved for a situation where the MD providing the anesthesia care was the same as the one documenting the Preop Assessment.

• Document “Risks Discussed” with the patient

• Document “Additional Equipment” discussed

• Document “Anesthesia Alerts”


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Notice how there are very few alerts to select. In the electronic medical record, “Anesthesia Alerts” are encounter specific (they are relevant to the current surgical procedure). All other alerts traditionally recorded on the paper record have been included in “Allergies and Precautions”. Precautions are patient specific. They follow the patient from one encounter to the next.

It will be very important to peruse the “Allergies and Precautions” section on the Summary Screen if there is something that you want seen on the OR Front Sheet.

For example, the patient you are currently reviewing has a history of malignant hyperthermia. As this label will follow the patient from one encounter to another, it should have been noted under “Allergies and Precautions”. In the case above, it was NOT noted. You will then have to go this section and add the precaution yourself. This is why the box is titled “Anesthesia Alerts (see also Precautions). It is meant to prompt you to read the current precautions that have been noted and to select additional ones from that section if required.


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If you make a comment regarding an alert in the Comment box, this will NOT be seen on the OR front sheet.


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2.2.10 Tests and Results

The purpose of the “Tests and Results” screen is to:• Note which tests have been pre-ordered for the “Assessment”

At the present time, there is NO integration between the Hospital lab systems and the SIMS software. Nurses will NOT be transcribing data into the software from the printed lab results. The MD will be able to transcribe lab values, test results, etc. at their own discretion.


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2.2.11 Record Status

Selecting the Record Status option from the Quick Menu will display the Record Status screen.

The purpose of the Record Status screen is to:

• Identify that the chart is ready; and

• Identify outstanding items.


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2.2.12 Signatures

Selecting the Signatures option from the Quick Menu will display the Signatures screen.

The purpose of the Signatures screen is to:

• Identify the original assessing RN and Physician;

• Identify the reviewing RN and Physician; and

• Identify the RN completing the final chart sign off.


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2.2.13 Addenda

Selecting the Addenda option from the Quick Menu will display the Addenda screen.

The purpose of the Addenda screen is to document any additional patient information after final chart sign off (e.g., late entry, telephone inquiry).

This section will be also be used by the MD to summarize the preop assessment if required (eg. Consultation).


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2.2.14 Copy Forward

Selecting the Copy Forward option from the Quick Menu will display the Copy Forward screen.

The purpose of the Copy Forward screen is to retrieve a patient’s Current Medications, MD Assessment and Nursing Health Assessment/Vital Signs from a previous visit.


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3 HANDS-ON EXERCISES

This section contains a number of hands-on exercises designed to train a user to perform a pre-operative evaluation of a patient.

3.1 Getting Started

To start SIMS Preop Manager:

1. Double-click the SIMS Preop Manager icon on your desktop.

When you launch SIMS Preop Manager, the CareSuite Logon screen is displayed.

To logon to SIMS Preop Manager:

2. Type your user name in the User Name field.

3. Type your password in the Password field.

4. Click OK.


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MD Training ManualAfter successfully logging in to SIMS Preop Manager, the Census List screen is displayed.


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3.2 Record Status Workflow

Nurse/Anesthesia PAU Clinic Visit

Patient is Assessed by Nurse

Any outstanding items are indicated by assigning one of the following recordstatuses: Oustanding Lab/Diagnostic Test Results Oustanding Consults Outstanding Follow-up Calls Outstanding Records

Note: If there is more than one Record Status to be associated with a patient,the primary status should be selected and any remaining status should beentered in the Comments field

Patient is assessed by Physician

Nurse completes chart review


Abnormal labs are received and need to be reviewedby the Physician

Record status is set to Pending Anesthesia Review

Anesthesia reviews abnormal labs

Record status is set to Anesthesia Review Complete


If chart is complete record status is set to Ready forSurgery and Final Chart Sign Off is completed

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Patient is Assessed by Nurse


Note: If there is more than one Record Status to be associated with a patient,the primary status should be selected and any remaining status should beentered in the Comments field

Nurse determines that Anesthesia Consult is required

Record status is set to Outstanding Consults. In the comments section wouldindicate that record is awaiting Anesthesia consult.

Anesthesia performs Consult


If chart is complete record status is set to Ready forSurgery and Final Chart Sign Off is completed


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3.3 Searching For a Patient

3.3.1 Searching For a Patient by MRN

To search for a patient by their MRN, at the Census List screen:

1. Type the patient’s MRN in the Patient ID field.

2. Click Find.

A list containing the patient with the entered MRN is displayed.


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MD Training ManualNote: When searching for a patient by Last Name or MRN, there may be multiple records returned in the search results. The user should ensure that they have selected the patient with the correct Last Name, First Name, MRN and DOB. As well, the user should ensure they have selected the record with the appropriate Booked Preop Date and that the Clinic Code matches your facility.


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3.3.2 Searching For a Patient by Last Name

To search for a patient by their last name, at the Census List screen:

1. Type the patient’s last name in the Last Name field.

2. Click Find.

A list of all patients with the entered last name is displayed.


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MD Training ManualNote: When searching for a patient by Last Name or MRN, there may be multiple records returned in the search results. The user should ensure that they have selected the patient with the correct Last Name, First Name, MRN and DOB. As well, the user should ensure they have selected the record with the appropriate Booked Preop Date and that the Clinic Code matches your facility.


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3.3.3 Searching for a Patient by Today’s Visits

To search for a patient who is scheduled for a PAU visit today, at the Census List screen:

1. Select a Census Type of Preop patients - Scheduled for today.

A list of all preop patients scheduled for today is displayed.


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MD Training ManualNote: Patients listed on the Census List screen can be sorted by clicking on the provided column headings. For example, clicking on the DOB column heading will sort the listed patients by their date of birth.


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3.4 Documenting a Patient

3.4.1 Simple Complexity Case Scenario

You are seeing a 55 y.o. female for laparascopic cholecystectomy.Vital signs normal.Weight 80 kg. BMI of 30

She had previous general anesthesia without complications and a negative family history.The patient is hypertensive-well controlled on a diuretic with a BP of 140/92She does not experience chest pain and walks 18 holes of golf on a regular basis.She is an ex-smoker since 2000, history of 25 pack years.She does not experience any residual effects secondary to her smoking.She is obese but denies GE reflux.

On exam, she appears in no apparent distressAirway is assessed as Mallampati Class II.CVS and Resp. exam are WNL.

You classify this patient as an ASA IIYou discuss routine General Anesthesia with the patient. She asks a few questions specific to postop nausea/vomiting. You address her concerns.

Demographic and vital sign information for this patient will be populated by the appropriate individual (not MD). You do NOT have to enter in name, age, date of birth, procedure, etc.

1. Click the MD Assessment .The MD Assessment screen is displayed.2. Click on RoS-Anes Hx. 3. There will be two boxes on all submenus located on the right hand side of the

screen; the top box contains descriptors classified as “normal”. The bottom box contains descriptors classified as “abnormal”. Place the cursor over “no previous anesthetics” in the upper (normal findings) box. Click so that a checkmark appears in this box.


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4. Notice the scroll-down bar within the “normal findings” box. Scroll down and you will see the descriptor “no abnormal family history”. Click so that a checkmark appears in this box.

You have finished your entries in this submenu. If you hit “OK” at the bottom right, you will return to the Patient Summary Screen. To move to the next part of the assessment, you will click on RoS-Cardiovascular 1 under “Body System” on the left of the screen.


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5. The patient has a BP of 140/92. Place the cursor over the box with the descriptor, “Stage 1 Hypertension BP 140-159/90-99 and click so that a checkmark appears in that box. To the right of this descriptor, place your mouse in the “comment” box and click so that the field becomes active. Type, “well controlled on diuretics.”

You have finished your entries in this submenu. If you hit “OK” at the bottom right, you will return to the Patient Summary Screen. To move to the next part of the assessment, you will click on “RoS-Exercise Tol” under “Body System” on the left of the screen.

6. Here, you have a choice. You can either place your cursor over the box entitled, “MET > 4” or if you want to be more specific, you can place your cursor over the box entitled, “MET 7=golf, dancing, doubles tennis”. Check over the box.

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You have finished your entries in this submenu. If you hit “OK” at the bottom right, you will return to the Patient Summary Screen. To move to the next part of the assessment, you will click on “RoS-Respiratory System” under “Body System” on the left of the screen.

7. Although the patient is a smoker, she has quit and denies any sequelae. Move your cursor to the descriptor “No Respiratory problems” in the “normal findings” box. Click so that a check mark appears in the box.

You have finished your entries in this submenu. If you hit “OK” at the bottom right, you will return to the Patient Summary Screen. If we want to further describe her smoking history, you will click on “RoS-Social Habits-Pscyh-Chronic Pain” under “Body System” on the left of the screen.


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8. The patient has a 25 pack year history of smoking and quit in 2000. Move your cursor to the descriptor “cigarettes 20-30 pack years” in the “abnormal findings” box. Click so that a check mark appears in the box. To the right of this descriptor, place your mouse in the “comment” box and click so that the field becomes active. Type, “quit smoking in 2000”.

You have finished your entries in this submenu. If you hit “OK” at the bottom right, you will return to the Patient Summary Screen. To move to the next part of the assessment, you will click on “RoS- GI System” under “Body System” on the left of the screen.


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MD Training Manual9. The patient is obese but does not experience GE reflux. Move your cursor to the

descriptor “no GE reflux” in the “normal findings” box. Click so that a check mark appears in the box. Now, use the scroll down bar to identify the descriptor “obesity” in the “abnormal findings” box. Click so that a check mark appears in the box. We do not have to enter the BMI of 30 as this will be found under the “Admit Ht/Wt/BSA/BMI/Blood Type Quick menu” completed by the nurses.

You have finished your entries in this submenu. If you hit “OK” at the bottom right, you will return to the Patient Summary Screen. Notice how the Quick Menu item labelled “MD Assessment” has gone from white to yellow. This indicates that an entry has been made in this Quick Menu. To move to the next part of the assessment, you will click on “PE-General” under “Body System” on the left of the screen.

10.Move your cursor to the descriptor “awake, relaxed, cooperative” in the “normal findings” box. Click so that a check mark appears in the box. Move your cursor to the “obesity” descriptor in the “abnormal findings” box. Click so that a check mark appears in the box.


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You have finished your entries in this submenu. If you hit “OK” at the bottom right, you will return to the Patient Summary Screen. To move to the next part of the assessment, you will click on “PE-Airway” under “Body System” on the left of the screen.

11. Move your cursor to the descriptor, “A/W Class II (can see post pharyngeal wall)” in the “normal findings” box. Click so that a check mark appears in the box. Now, move your cursor to the descriptor, “No concerns”. Click so that a check mark appears in the box.

You have finished your entries in this submenu. If you hit “OK” at the bottom right, you will return to the Patient Summary Screen. To move to the next part of the assessment, you will click on “PE-CVS” under “Body System” on the left of the screen.


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12.Move your cursor to the descriptor, “WNL” in the “normal findings” box. Click so that a check mark appears in the box. Should you wish to be more detailed, you are free to check the other relevant descriptors in the “normal findings” box.

You have finished your entries in this submenu. If you hit “OK” at the bottom right, you will return to the Patient Summary Screen. To move to the next part of the assessment, you will click on “PE-Resp” under “Body System” on the left of the screen.


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13.Move your cursor to the descriptor, “WNL” in the “normal findings” box. Click so that a check mark appears in the box. Should you wish to be more detailed, you are free to check the other relevant descriptors in the “normal findings” box.


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Notice how the “Status” column looks as we complete each of the submenus. If there are only descriptors in the “normal findings” box checked, the status will read, “Normal”. If there are descriptors in both the “normal findings” and “abnormal findings” boxes checked, the status will read, “Normal with exceptions”. If there are descriptors in the “abnormal findings” box checked, the status will read, “Abnormal” If a submenu has not been entered, the status will read, “Deferred”.

The software cannot be programmed to insure that certain parts of the assessment have been completed. At the very least, a proper anesthesia assessment should have the following sections completed:

• RoS-Anes Hx• RoS-Cardiovascular 1• RoS-Respiratory• PE-Airway• PE-CVS• PE-Resp

You have finished your entries in this submenu. Hit “OK” at the bottom right. You will return to the Patient Summary Screen. Click on the “Anesthesia Plan” Quick Menu. You classify the patient as an ASA II, you discuss General Anesthesia and address her concerns regarding nausea and vomiting.


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14.Move your cursor to the pull down menu in the top box labelled “ASA”. Hit the DOWN arrow key, move your cursor over the “II” designation and click.

15.Move your cursor to the descriptor “General” in the “Anesthesia Technique Discussed” box. Click so that a check mark appears in the “Disc” box.

16.Move your cursor to the descriptor “All patient questions answered” in the “Risks Discussed” box. Click so that a check mark appears in the box.

17.Move your cursor to the Comments box. Type “concerned re: “discussed concerns related to nausea and vomiting”.

18.You have finished your entries in this Quick Menu. Hit “OK” at the bottom right. You will return to the Patient Summary Screen.


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19.Click on the “Signatures” Quick Menu. You are the “Assessing Physician”

20.Move your cursor into the “signature type” box and click in the circle next to “Assessing Physician”

21. If the patient has been seen by a student/resident and has subsequently been reviewed by you, move your cursor into the “signature type” box and click in the circle next to “Reviewing Physician”.

22.Move your cursor over the “Sign” button and click. You are presented with the dialogue box


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23.Move your cursor over the “Yes” button and click.

24.You will be prompted for your password. This is the same password you use to access the program.

25.The Patient Summary screen will appear as below.


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MD Training ManualNote: You are the reviewing physician when an assessment has been done by a student, resident or fellow. When the case is being reviewed, the trainee may pull up the case under his/her login credentials. When you sign as the reviewing physician, simply use the pull-down menu to find your “User Name”. You will then enter your Password and hit OK.

PRINTING THE RECORDUntil such time that the entire perioperative period is electronic (mid 2010), a paper copy of the record will be generated whenever a change to the Preop Assessment has occurred.

After the nurse has finished the preliminary assessment, the first paper copy will be printed and placed into the chart.

After completing the MD assessment, it will be important to print an updated paper record for the chart.

After reviewing lab/data/consults, it will be important to print an updated paper record for the chart (if you have made any changes to the assessment based on your review).

This record has been customized for The Ottawa Hospital. At the time of writing this manual, the functionality which would allow uploading to vOacis is not ready.


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3.4.2 Intermediate Complexity Case Scenario

You are seeing a 75 y.o. male booked for a colon resection/possible colostomy. He has a longstanding history of Crohn’s Disease and has undergone two previous bowel resections in the past. On the last occasion in 1995, he was told that he was a difficult intubation and now wears a Medic Alert bracelet. He also recalls that the Epidural took a long time and he experienced a lot of discomfort. He notes that he is not interested in any kind of regional procedure for the current procedure. Family anesthetic history is unremarkable.

This gentleman has coronary artery disease, NYHA class III angina. He has experienced 2 previous infarcts. In 1990, he had a single vessel CABG to his LAD. In 2007, he had a PCI to his RCA and has been on Plavix since that time. He has been admitted to the hospital on one occasion in 2007 for “water on the lungs”. He was placed on Lasix and Enalapril at that time. He does have swollen legs. Activity is limited to light work around the house. He can walk a few blocks but must stop to rest.

Regarding his Crohn’s Disease, he is currently on steroids, Prednisone 40 mg./day for the last few months.

He is a type II diabetic, taking oral hypoglycemics (metformin). He suffers from mild renal insufficiency-Cr. 150 and monitored on a regular basis.

He suffers from long standing arthritis of the knees and wrists.

He experiences panic attacks and takes a Bnz for this.

On examination, he has a typical steroid facial appearance and truncal obesity.You assess him as a Mallampati A/W Class 3. He’s got poor mouth opening, a thick neck, limited extension and a short chin.

CVS exam is significant for hepato-jugular reflux and peripheral edema, 2+ pitting to the knees. The patient has a systolic ejection murmur heard best along the sternal border. There are no carotid bruits.

Resp exam is significant for dullness to percussion and crackles at the bases.

vOacis reveals the following data:a. Echo Nov. 2008-multiple wall motion wall abnormalities. EF-40%b. EKG-first degree heart block. Previous IWMI, AWMI


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MD Training ManualYou discuss anesthetic options with this patient. He is adamant regarding his desire NOT to have an epidural despite explaining the benefits to him. You discuss the probability of an awake intubation, invasive lines, potential blood and blood products, post op ventilation.

Click the MD Assessment. The MD Assessment screen is displayed. Check the appropriate boxes in the respective submenu as per the case description.

Notice how the comments to expand on “intubation-difficult” and “other personal hx” seem cut off. The “Comments” field will only allow a fixed number of characters to be viewed.


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Rest assured that the entire contents of the comment will be transcribed to the patient summary screen.

Another option would be to enter the comments in the “RoS-Anes Hx Comments” box at the bottom of the screen.

Remember to scroll down to insure selecting the relevant descriptors. Over time, descriptor location within a submenu will become second nature.


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In this submenu, I placed the comment regarding steroid usage in the “RoS-GI System Comments” box instead of in the comment field beside the check box for “Inflammatory Bowel Disease (Crohn’s)”.


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The Review of Systems is now complete. We will now move on to the Physical Exam.

In this case, there was no appropriate descriptor in the “abnormal findings” that communicated the steroid changes to body habitus. I added them to the “General Comments” section.


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The Physical Exam is now complete. The Patient Summary appears as follows:

We will now proceed to “Tests and Results”


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There are several columns in this Quick Menu. “Order” refers to whether the test has been ordered by the physician. “Test” is self explanatory. “Result” is also self explanatory. At the present time, this entire menu will appear blank. Lab and test results will NOT be automatically populated via integration with other Hospital computer networks. In the future, we are hoping that integration will occur. The nurses will not be transcribing results from paper to the electronic record. Noting lab results on the electronic record will currently be done at the discretion of the physician. Lab result data (paper) will accompany the patient to the OR.

In this scenario, I have summarized the results of the EKG and the Echocardiogram from information that accompanies the patient or that can be obtained from vOacis. The resulting “Patient Summary” screen appears below. Notice how the system informs the user that these results are “User Entered”


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Another way of entering the results is by opening vOacis, navigating to the relevant test and then using the “copy and paste” functionality of the PC.

As an example, I have logged on to vOacis and pulled up an EP Neuroscience Study on my elbow (unrelated to this case).

I have highlighted the information that I want to place into Preop Manager “Tests and Results”. Now, use your keyboard-hold down the “Control” key and hit the letter “C”. This will save the highlighted text to your “clipboard”. Now, return to Preop Manager. There is no “Electrodiagnostic Study” available so I will place it into the “Comment Box” by clicking in this box (which makes it active). Now, use your keyboard-hold down the “Control” key and hit the letter “V”. This will paste the material on the clipboard into the selected box.


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The resulting “Patient Summary” screen appears below.


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MD Training ManualWe will now proceed to the “Anesthesia Plan”.

By hitting the “Show only items selected for Anesthesia Plan”, you get the following:


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I have classified this patient as an ASA 4, discussed GA/Epidural and awake intubation. I talked to the patient about invasive lines, the potential for PACU/ICU postop. In addition, I discussed blood/blood products and possible postop ventilation.

As this patient is not straight forward, I have decided to create a summary note. This will be done in the “Addenda” Quick Menu.



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I forgot to mention that the patient is a known difficult intubation and is aware of the potential for awake intubation. If I return to the Addenda Quick Menu and try to add this to my existing summary, it will NOT be possible to add additional information. At this point, you have two options. First, you can enter additional information. To do this, click on the “New” button on the bottom left.

This will bring up a new blank box for entry.


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MD Training ManualType in the additional information.


Alternatively, you can delete an entry by placing your cursor on the number of the entry you wish to delete. Your mouse arrow changes to a “right pointing horizontal arrow” when placed on the number of the entry you wish to delete. “Left click and the “addenda” box is highlighted in black and the “delete” key at the bottom of the menu is no longer greyed out. Hit the delete key and the comment will disappear.


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The Assessment is now complete.

You now have to sign the document as either the Assessing or Reviewing Physician. You are the reviewing physician if you have not done the initial assessment.


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The Assessment is complete.


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MD Training Manual3.4.3 Reviewing Abnormal Results/Lab Data

A nursing/anesthetic pre-assessment can only be signed off as “ready for surgery” when all outstanding lab results, tests and consultations have been reviewed. Often, we are asked to review much of this documentation.

During the course of a working day in the PAU, it will be necessary to review these patients.

Open the application and pull down the census list, highlighting “Pending Anesthesia Review”.

Select a patient. Remember that we are currently working in a hybrid environment. We will continue to have a paper chart. At this point, most things that require review will be in paper form, whether that is lab results, tests, consults or general information.

The system in place to notify the physician as to what requires review differs slightly from campus to campus.

Review what is required and signoff as per usual on the paper record.

At this point, you have several options. \\c-gen-fp1\IS\Projects\ICT StrategicPlan Programs & Projects\ORProject\Training\Pre-OperativeEvaluation RN Training Manual.doc

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MD Training Manual1. You may choose not to do anything. 2. You can navigate to the appropriate submenu of the “MD Assessment” Quick

Menu and summarize the reviewed document in a manner that you decide is most appropriate. This could either be as an entry beside one of the descriptors that you have ticked off in the “abnormal findings” box or in the “Comments” section.

3. You may choose the “Addenda” Quick Menu and enter text here.

If you are reviewing an abnormal lab/test result, you may choose the “Tests and Results” submenu. Again, you may summarize in the “Result” field beside the particular test or make a note in the comments box. Alternatively, you can log into vOacis, find the particular test and then copy/paste into the area that you choose.

When the review is complete, you must document your activity electronically. Go to the “Record Status” Quick Menu and use the pull down list to highlight “Anesthesia Review Complete”. This will move the patient out of the census “Pending Anesthesia Review”.

Finish your documentation by signing the chart. Go to the “Signature” Quick Menu and tick in the box labelled “Reviewing Physician.” You may also add in comments relevant to the review at this time.


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Move your cursor over the “Sign” button and click.

.


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The Patient Summary screen appears as follows:

You are now ready to either logoff or move to the next patient for review.


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3.5 Self Study Scenario

Age: 53Diagnosis: Right Middle Lobe Bronchogenic Carcinoma

History:

This 53 year old man presented 3 months ago with blood-streaked sputum and subsequent investigations (needle biopsy) revealed a squamous cell carcinoma of the RML causing collapse of the RML and extension of the tumour to involve the bronchus to the RUL. He is booked for bronchoscopy and cervical mediastinoscopy and right pneumonectomy.

This patient has a 35 pack-year smoking history but quit 3 months ago. He has a chronic cough with AM sputum. There has been some deterioration in his exercise tolerance in the past 3 months. He cannot recall the last time he climbed stairs but doubts that now he could do more than 1 flight without stopping for a rest. He gets breathless with exertion but says he can do most routine activities of daily living. He has no problems sleeping: no orthopnea, no PND, no sleep apnea. There has been no history of ankle edema. There is no evidence of paraneoplastic syndromes. He has been using Ventolin and Atrovent puffers 4x’s daily for the past 5 years.

With regard to the rest of the Review of Systems:

He has had previous GAs without incident but only in the remote past (appendectomy, ORIF radius). There is no family history of GA problems.

He has been treated for Hypertension with perindopril (Coversyl) and a diuretic for the past 5 years and his BP is well-controlled. He has never had angina or a myocardial infarction, nor history of CHF or arrhythmias. He takes ASA 81 mg because his Family MD says it is good for him.

He has mild GE reflux that is well-controlled with esomeprazole (Nexium). He has diabetes type 2 which is well-controlled with metformin. There is mild osteoarthritis of the left hip for which he takes the occasional NSAID (ibuprofen). No CNS problems. Drinks 2 beers a day – no binge drinking. No recreational drugs.


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MD Training ManualOn examination:

Vital Signs (from Nurse Assess): BP 135/85 HR 88 Wt 87 kg BMI 30

Looks older than 53 years. In no apparent distress but gets a bit breathless undressing. Not cyanotic.

Has upper partial plate for missing top incisors. Voice normal. Mallampati class III airway. Thyromental distance is greater than 3 finger breadths. Neck extension normal.

Somewhat barrel-chested and has mild finger-clubbing. Breath sounds are decreased on right anteriorly. There is some wheezing on the right that clears with coughing.

Heart size appears normal. Rate/rhythm normal. S1-S2 normal, no S3, no murmurs. No jugular venous distension, no peripheral edema.

Abdomen soft, non-tender, no organomegaly. Neurologic exam – grossly intact

Supplementary Information (from vOacis):

ECG: Normal sinus rhythm; axis WNL; PR interval & QRS width normal; no evidence of RVH

CXR: Mild hyperinflation of chest with some flattening of diaphragms; collapse of RML with evidence of tumour mass encroaching on the R hilum; no increase in vascular markings; heart normal size

CT Scan: Tumour has completely obstructed the RML bronchus with resultant collapse of the distal lung tissue. Tumour appears to have extended into the RUL bonchus without significant occlusion.

Pulmonary Function Tests:ABG (rm air): pH 7.45 PCO2 = 44 PO2 = 78Spirometry:

Pre-bronchdilator:FVC = 60% pred. FEV1 = 1.4L (35% pred) FEV1/FVC = 50%

predPost-bronchodilator:

FVC = 60% pred. FEV1 = 1.6L (40% pred) FEV1/FVC = 55% pred


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MD Training ManualMax Voluntary Vent = 55% predMax O2 consump (VO2max) = 13 mL/Kg/minDLCO = 40%

Ventilation-Perfusion Scan: Matched perfusion and ventilation defect middle third right lung. There is volume loss with decreased perfusion to remaining right lung. Majority of the pulmonary perfusion and ventilation is from the left lung.

Differential Lung perfusion as percent of total perfusion:Location Right LeftUpper Third 9% 30%Middle Third 1% 20%Lower Third 10% 30%Total: 20% 80%

Differential Lung Ventilation as percent of total ventilation:Location Right LeftUpper Third 7% 32%Middle Third 0% 21%Lower Third 12% 28%Total: 19% 81%

Predicted Post op FEV1 = 1.1

Echocardiogram:LV function normal – EF = 50%; no abnormal wall motionRV function normal – no evidence of pulmonary hypertensionHeart valves – normal function

Blood Tests:Hgb 165 Platelets 240Na 135 K 3.8 Cl 105 CO2 25 Creat 78INR 1.1


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MD Training ManualNote from Surgeon:

“With his pre-existing COPD and the initial PFTs, this patient did not appear to be a candidate for surgery. The CT scan would suggest that the tumour is resectable but there is a high likelihood the patient will require a pneumonectomy and it was unclear if the patient could tolerate the procedure. A V/Q scan showed that almost two-thirds of the right lung does not contribute to effective ventilation and that a predicted postop FEV1 would be in the range of 1.1L. The patient insists that his exercise tolerance decreased markedly in the past 3 or 4 months, possibly related to his tumour growth. The echo shows no evidence of pulmonary hypertension. Based on these factors I feel the risks of surgery and postop ventilatory problems are acceptable.”

Discussion with Patient:

Thoracic epiduralArterial lineInductionIntubation with DL tubeBlood transfusionPACU stay – overnight? Possible ICU stay


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Entering the data in Preop Manager

Once you have located the patient in the census list for Preop Evaluation and opened the file, you will presented with the screen showing data entered so far by admitting clerks and the PAU nurses. Once you have verified that you have the correct patient by checking the header with patient name and MRN, you are ready to proceed.

You will notice that the assessing nurse has indicated that there are No Known Medication Allergies and that, regarding Current Medications, you should refer to the Medication Reconciliation Form, since this patient will an in-patient.

The assessing nurse has completed the following section:

Try to scroll this section to the top of the computer screen for later easier access while in entering data in the next section, the MD Assessment.

Beginning with RoS-AnesHx, you will want to check the appropriate boxes for Previous GA without complications and No abnormal Family History.

The next section RoS-CVS1 has important data to enter. Your patient is a known hypertensive, treated for the past 5 years on an ACE inhibitor and a diuretic. You will want to check off the box for Stage I Hypertension and add a comment such as “x5 years” and check off the box that indicates the patient is on the ACEI. The patient has no other relevant CVS info to record but if you wish to document significant negative data you could use the bottom comment field to type: “No angina, no MIs”.

The next section RoS-CVS2 , regarding CHF, Valvular HD and Arrhythmias, does not apply to this patient so you can skip this section.


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The next section RoS-Respiratory System will document much of the important history of this patient’s illness.

It certainly sounds like he has COPD(Bronchitis) so checking that box is appropriate. If you add in the comment field “AM cough with sputum,” you will discover a little further down under “Common Issues” a box for “Productive Cough”. Rather than deleting and re-typing, you can highlight the previously entered phrase, press ctrl-X, (the phrase “disappears”) then move to the new comment field and press ctrl-V (the phrase re-appears). Add also the use of bronchodilators.

You will want to try to quantify his level of dyspnea. Based on what he tells you, he is probably Class 3 Dyspnea, recent onset. So it will be appropriate to check the box but to also add a comment.


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When documenting this patient’s lung cancer, you have some information from the patient himself and considerably more from the referring surgeon. You can check off the Lung Cancer box and also add the facts about the collapsed RML by tumour, with invasion into the RUL bronchus. You can also add that it is biopsy-proven squamous cell carcinoma.

In the RoS-Exercise Tolerance section, you decide that he operates somewhere between 2 and 3 METS so you check both boxes.

The remaining history obtained can be covered by quickly by the following:RoS-GI System – check “GE Reflux (controlled by drugs)”RoS-Endocrine – check both “Diabetes Mellitus - type 2” and “+ oral hypoglycemics”RoS-Musculoskeletal – check “Arthritis – Osteoarthritis” and add “L hip – occ’l NSAID”

as a commentRoS-Social Habits – check “Cigarettes 30-50 pack years” and “Alcohol < 3 drinks per

day”


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MD Training ManualMoving on to the Physical Exam, you may wish to make a PE-General statement about the patient’s appearance and demeanor. Perhaps check off “well-developed, well-nourished, no acute distress” but add: “Gets a bit breathless undressing. Not cyanotic.”

The next relevant section is PE-Airway. You want to assign him a Mallampati class of 3, which is an abnormal finding. You want to mention about his partial upper denture for missing top incisors. The checkboxes and comments could look like this:

Similarly, the findings of examination of the chest can be documented as follows:


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The rest of the physical exam is very straight-forward to document – everything is normal.

Laboratory Tests / Investigations and Preop Manager

With patients referred by a service such as Thoracic Surgery, there will be a lot of accompanying reports and data available when you see the patient. Much of this data will be available on vOacis. The decision you need to make is how much do you want to summarize within Preop Manager and how much do you leave for your colleague to look up the details on vOacis. Also, you may want to evaluate and document the investigations prior to documenting the anesthetic plans discussed with the patient.

The ECG report on vOacis is essentially a picture with report included at the top. You cannot copy and paste the text of the report. Therefore you will need to type into Preop Manager in the section:

Similarly, the ABG result has been entered.

For reports such as Chest X-Rays, CT scans and Cardiac Echos, you can highlight the summary section, copy it and paste it into the relevant section of the Test and Results section of Preop Manager.


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The space for cutting and pasting text is fairly generous but it IS limited to a good-sized paragraph. Formatting of the text gets lost in the process, so it is not perfect. Looking at the Ventilation-Perfusion Scan report, you might be tempted to try and copy the tables of numbers provided. It does not work – all the table values get jumbled up. You can paste two different text clips into the same box in Preop Manager. Paste the first clip in as usual; then for the second clip, place your cursor at the end of the previously pasted text and press ctrl-V. To make a new line within the box, you need to press shift-Enter, not Enter by itself. Note that some of the text pasted into the box may scroll up and out of view. It’s still there – just scroll up with the cursor.

So the final result of the data entry for Investigations should look like this:

You now need to document what you discussed with the patient regarding the anesthetic, the procedures involved and associated risks. This is the screen where you need to decide what ASA score you will assign. Your screen will probably resemble this one (assuming that you checked the little box at the lower right to hide all the unchecked boxes):


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One more task that you opt to complete is to document within Preop Manager this patient’s Current Medications. This patient will be an in-patient so the assessing nurse will not enter the medications but will refer readers to the separate Medication Reconciliation Sheet which will be on the patient’s paper chart. (Some day in the future this too will be computerized – but not in Preop Manager, sadly.) So it is up to you to decide if you wish to add the important medications this patient is taking at home.

When you open the Current Medications section you are presented with a screen like this:


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You MUST leave untouched the current line with the phrase “See Medication Reconciliation Form”. You should click on the button “New Row” and you will then see a Search Form:

You can enter the first few letters of either the generic or brand name of a drug and click on “Find Now”. You may get a list of drugs as a result; just click on the name you want to enter. Add more rows as needed and search for more names of drugs. You can add details if you wish or just be satisfied with a list of drug names. Click “OK” when done.

Note: The first line entered by the assessing nurse regarding the Med Rec Form is still there!


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The final task is to summarize your assessment of this patient in the Addenda section. Here is an example:

You then remember that you forgot to mention that you plan to stop his ACE inhibitor 24 hours preop, so you click “New” and add another note in the Addenda section. The final result looks something like this:

You are now finished entering the data for this scenario.


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APPENDIX APRE-OPERATIVE EVALUATION REPORT EXAMPLE

TBD: Waiting for vendor to complete report before an example can be inserted here


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sims preop manager pre-operative evaluation rn training...

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