Transcript Electronic Signature for Operative Rep (PPT Only)

Electronic Signature
for Operative Reports
Joy Pasternock EVS, HDS
Scott Ridings EVS, HDS
Objectives
• Provide an Overview
• Review Installation & Site Parameters
• Review Signing Operative Reports
Overview
Surgery Electronic Signature
Enhancements
• Provides the ability to electronically sign
operative reports contained within the
VISTA Surgery application.
• Provides the ability to view these signed
reports on the Surgery Tab in CPRS by
storing them in the Text Integration
Utilities (TIU) package.
Reports
• Operation Report
• Nurse Intraoperative Report
• Anesthesia Report
• Procedure Report (Non-O.R.)
Operation and Procedure
(Non-O.R.) Reports
• Summaries are signed using the Surgery tab
or TIU functions
• Cannot be signed using options within the
Surgery package
• Surgeon is legally responsible for signing the
dictated Operative Summary section of the
Operation Report
Nurse Intraoperative Report
and Anesthesia Report
• Comprised primarily of information contained in
specific fields entered through the Surgery
package as opposed to a dictated summary
• Signed using Surgery options only
• Cannot be signed directly from the Surgery Tab
• Uploaded into the TIU software upon signature
– Viewable on the Surgery tab within CPRS
Nurse Intraoperative Report and
Anesthesia Report Addenda
• Addenda for these reports are also
created solely within Surgery options
• Controlling the process within Surgery
options
– Signed report and information contained
within the Surgery files remains the same
Installation
and
Site Parameters
Installation of the Surgery
Enhancement
• Surgery patch (SR*3*100) provides
the Electronic Signature for
Operative Reports enhancements
• Prior to installing the patch, several
setup issues need to be resolved
Requirements Prior to
Installation
• The Text Integration Utilities patch
TIU*1*112 must be installed prior to
the Surgery patch (SR*3*100)
• The document definitions for the
Operation Reports defined using the
TIU options
Worksheet Completion
• Worksheet is provided with the Installation
Guide
• Completed by the Surgery Application
Coordinator with input
– Clinical Application Coordinator
– Other key Surgery staff
• Provide completed worksheet to IRM installer
• Do not install the Surgery patch without a
completed worksheet
New Surgery Parameter
• Determine if your Medical Center Uses the
Anesthesia Report
• New Parameter
– ‘ANESTHESIA REPORT IN USE’
• Prompted during installation
• Changed after installation
– Use the Surgery Package Management Menu
• Values
– No – Default
– Yes
Default Clinic for Documents
• One of the new site parameters included with this patch is the
DEFAULT CLINIC FOR DOCUMENTS parameter.
– This non-count clinic will be the location passed to TIU, and is used to
establish an encounter when Surgery documents are created if no other
location can be identified.
• Enter this parameter immediately following patch installation using
the Surgery Site Parameters (Enter/Edit) option.
– Before entering this parameter, it may be necessary to create an active,
non-count clinic in the HOSPITAL LOCATION file (#44), if a suitable one
does not already exist.
• The default clinic will ensure that each surgery document will be
linked to a clinic in the same division where the surgery occurred.
– It is recommended that multidivisional facilities define a clinic for each
Surgery Site defined in the SURGERY SITE PARAMETERS file (#133)
to ensure document linkage to the proper division.
Converting Reports
• Identify existing cases that should be
electronically signed using the new software
• Determine which reports for existing cases will
be viewable through CPRS, but not
electronically signed
• Update cases created with the Boston Class III
software
Determine Existing Cases that should
be signed using the New Features
• During installation
– Identify existing Surgery cases that will
have reports electronically signed using
the new features provided by the
Electronic Signature for Operative
Reports enhancement
Existing Cases Electronically
Signed using New Features
• All reports for all completed cases within the
date range selected are included
– Case already has an uploaded surgeon’s
dictation
– Signed paper copy of the Operation Report
• All associated operative reports will require
electronic signature for that case
Converting Reports
Enter the Starting Date for Reports to be signed electronically: 05/01/04
During the Post-Installation process, all reports for cases with an
operation date on or after MAY 1, 2004 will be identified to be signed
electronically.
Benefits
• Convenience to users
– Ability to electronically sign vs. wet signature
– Eliminates searching down paper copies
• Provides a practical medical record
– Easier to locate reports
• Medical Record reviews
• JCAHO visits
– Eliminates dual system
• Consistent method for signing & viewing reports
similar to other TIU documents
Disadvantages
• Some Reports already signed on paper
will now also require an electronic
signature
• Additional upload of previously
authenticated documents
• Staff members may have left facility
– Business Rules to allow COS or Service Chief to
sign
Making Reports for Existing
Cases Viewable through CPRS
• Determine beginning date to include/view
cases prior to installation
• Consider the reports to include
– Operation Report
– Nurse Intraoperative Report
– Anesthesia Report
– Procedure (non-or) Report
• Complete the Worksheet
Enter the Starting Date for Reports to be moved: 01/01/1995
Do you want to move the Operation Reports? NO// YES
Do you want to move the Nurse Intraoperative Reports? NO// YES
Do you want to move the Anesthesia Reports? NO// <Enter>
Do you want to move the Procedure(Non-O.R.)Reports? NO// <Enter>
During the Post-Installation process, the following reports will be moved for
the date range January 1, 1995 through May 1, 2004:
Operation Report
Nurse Intraoperative Report
New Surgery Package
Management Menu Option
• New Option in Surgery Software
– Make Reports Viewable in CPRS
– Allows moving additional reports for other date
ranges after installation of the software
Make Reports Viewable In
CPRS
• CAUTION!!
– This is a system intensive process that
creates new documents in TIU
– Please ensure adequate disk space
availability before running this process.
– Late activity messages may be suppressed by
disabling the mail group defined as the "Late
Activity Mail Group" while this process runs.
This mail group must be re-established after
completion
Disclaimer
• Shown when displaying reports for
existing cases that have not been
electronically signed
• Alerts the reader that the information
was not electronically signed
Disclaimer Text
• “This information is provided from historical
files and cannot be verified that the author
has authenticated/approved this
information. The authenticated source
document in the patient’s medical record
should be reviewed to ensure that all
information concerning this event has been
reviewed or noted.”
Converting Reports Created with
the Boston Class III Software
• Boston VA Class III Software
• Automatically converted to the new
format during the installation of the
Surgery patch
• Viewable through the Surgery tab and
not Progress Notes
Electronically Signing
Operative Reports
Signing/Editing Operative
Reports
• Operation Report and Procedure
Report (Non-O.R.)
– CPRS GUI / Surgery Tab
– TIU
• Nurse Intraoperative Report and
Anesthesia Report
– VistA Surgery Package
Procedure Report (Non-O.R. )
• New field added to the Edit Non-O.R.
Procedure option
– Determines whether a Procedure Summary gets
created for this specific case
– Values
• No Entry (Null) - no summary will be created
• YES - the process for creating a summary will be
similar to the Operation Report process explained in
the following slides
Operation Report
• TIME PAT OUT OR
– Time patient leaves operating room
– A stub entry for the Operation Report
is created within the TIU package
Stub
Operation Report Ready for
Signature
• Dictated & transcribed
• Uploaded into TIU
• TIU parameter settings determine when view
alert is sent to surgeon/attending
–
–
–
–
Release of documents
MAS Verification
Signature Requirements
Co-Signers
• Alert signals Operation Report is ready for
signature
TIU Parameters
• REQUIRE RELEASE:
– Determines whether the person entering
the document is required (and
prompted) to release the document from
a draft state upon exit from the
entry/editing process
– Values
• No
• Yes
TIU Parameters cont.
• REQUIRE MAS VERIFICATION:
– Determines whether verification by MAS is
required, prior to public access and signature
of the document
– Values
• NO
• YES, ALWAYS – Documents require verification regardless
how they originate
• Upload Only – Require verification when documents are
uploaded
• Direct Entry - Verification is required only when documents
are entered directly into VISTA
TIU Parameters Cont.
• REQUIRE AUTHOR TO SIGN:
– Indicates whether or not the author should sign the
document before the expected cosigner (attending)
– Values
• No
– Only the expected cosigner is alerted for signature
– Unsigned document appears in the author's unsigned list, and
is ALLOWED to sign it, signature is not REQUIRED
• Yes
– author is alerted for signature
– If the expected cosigner should attempt to sign the document
first, they are informed that the author has not yet signed
TIU Parameters Cont.
• SEND COSIGNATURE ALERT:
– Controls the sequence in which alerts are
sent to the expected cosigner of a document
– Values
• After Author has SIGNED
• Immediately
Notification for the Operation
Report
• Displays the report is ready for
signature
• Selecting the alert
– Takes Surgeon to CPRS/Surgery tab
• The following slide display shows the
unsigned Operation Report
Operation Report
• After signature
– Operation Report viewable on
the Surgery tab to other users
Signing the Nurse Intraoperative
Report and Anesthesia Report
• Process is the same
– Uses data elements within Surgery
package
• Reports can only be signed
within VistA Surgery functions
Notification to Sign Nurse
Intraoperative Report
• TIME PAT OUT OR
– The time the patient leaves the operating room is entered
– Notification is sent to Circulating Nurse that the Nurse
Intraoperative Report is ready for signature
• Acting on the alert
– Nurse taken to the Nurse Intraoperative Report option
within the Surgery package
– Report Options
•
•
•
•
Display
Print
Edit
Electronically sign
Nurse Intraoperative Report
Required Fields
• TIME PAT IN OR
• TIME PAT OUT OR
• Count Related Fields (if COUNTS VERIFIED
BY has been entered)
• MARKED SITE CONFIRMED
• PREOPERATIVE IMAGING CONFIRMED
• TIME OUT VERIFIED
VeHUPatient, One (000-00-0001)
MEDICAL RECORD
Operating Room:
NURSE INTRAOPERATIVE REPORT - CASE #000001
WX OR3
PAGE 1
Surgical Priority: ELECTIVE
Patient in Hold: FEB 12, 2004 07:30
Patient in OR: FEB 12, 2004
08:00
Operation Begin: FEB 12, 2004 08:58
Operation End: FEB 12, 2004
12:10
Surgeon in OR:
Patient Out OR: FEB 12, 2004
12:15
FEB 12, 2004 07:55
Major Operations Performed:
Primary: MVR
Other:
ATRIAL SEPTAL DEFECT REPAIR
Other:
TEE
Wound Classification: CLEAN
Operation Disposition: SICU
Discharged Via: ICU BED
Press <return> to continue, 'A' to access Nurse Intraoperative Report
functions, or '^' to exit: A
Nurse Intraoperative Report
Functions
• All information is reviewed &
completed
• Editing has been completed
• “Sign the report” function
Press <return> to continue, 'A' to access Nurse Intraoperative
Report functions, or '^' to exit: A
VeHUPatient, One (000-00-0001) Case #000001 - MAY 1, 2004
Nurse Intraoperative Report Functions:
1. Edit report information
2. Print/View report from beginning
3. Sign the report
Select number: 3// <Enter>
Signed Nurse Intraoperative
Report
• Moves into TIU files
• Viewable on the Surgery tab
Nurse Intraoperative Report
Addenda
• Changes to information contained
on the report require an
electronically signed addendum
• Created from any of the data entry
options within the Surgery package
Nurse Intraoperative Report
Addenda
• Entering the data entry option
– User is alerted that the report has
been signed
• Snapshot of the current record is
stored
– In the background
– Transparent to the user
Nurse Intraoperative Report
Addenda
>>> WARNING <<<
Electronically signed reports are associated with this case. Editing
of data that appear on electronically signed reports will require the
creation of addenda to the signed reports.
Nurse Intraoperative Report
Addenda
• Exiting the data entry option
–Second snapshot is taken
–Compared with the original
• Any changes create an
addendum
VeHUPatient, One (000-00-0001) Case #000001 – MAY 1,2004
An addendum to each of the following electronically signed document(s) is
required:
Nurse Intraoperative Report - Case # 000001
If you choose not to create an addendum, the original data will be restored
to the modified fields appearing on the signed reports.
Create addendum? YES// <Enter>
Addendum to Nurse Intraoperative Report for Case #000001 – MAY 1,2004
Patient: VeHUPatient, One (000-00-0001)
-----------------------------------------------------------------------------------------------------The Count Verifier field was changed
from VeHUNurse, One
to VeHUNurse, Two
Do you want to add a comment? YES// NO
Enter your Current Signature Code: XXXXX SIGNATURE VERIFIED
Nurse Intraoperative Report
Addenda
• The user elects not to sign the
addendum
– All changes made will be backed out
– Restores the database to reflect what
was originally signed on the report
MEDICAL RECORD
NURSE INTRAOPERATIVE REPORT
PAGE 1
Case # 001
Operating Room: OR1
Surgical Priority: ELECTIVE
Patient in Hold: MAY 01, 2004 09:00
Patient in OR: MAY 01, 2004 09:30
ESU Cutting Range:
N/A
Electroground Position(s):
N/A
Tubes and Drains:
Operation Begin: MAY 01, 2004 09:45
Surgeon in OR: NOT ENTERED
PENROSE, CYSTIC DUCT STUMP EXTERIORIZED TO LATERAL ABDOMINAL WALL
Operation End: MAY 01, 2004 12:30
Patient Out OR: MAY 01, 2004 12:40
Medications:
DIAZEPAM 5MG/ML 2ML SYRINGE
Major Operations Performed:
Time Administered: MAY 01, 2004 09:55
Primary: CHOLECYSTECTOMY
Wound Classification: CLEAN
Route: INTRAVENOUS
Dosage: 10mg
Ordered By: VeHUProvider, One
Admin By: VeHUNurse, Four
Comments: N/A
Operation Disposition: PACU (RECOVERY ROOM)
Discharged Via: STRETCHER
Irrigation Solution(s):
NORMAL SALINE
Surgeon: VeHUProvider, One
First Assist: VeHUNurse, One
Attend Surg: VeHUProvider, Two
Second Assist: N/A
Anesthetist: VeHUProvider, Three
Assistant Anesth: VeHUNurse, Two
OR Support Personnel:
Time Used: MAY 01, 2001 10:05
Amount: 1000
Provider: VeHUProvider, One
Sponge Count:
YES
Sharps Count:
YES
Scrubbed
Circulating
Instrument Count: YES
VeHUNurse, Three
VeHUNurse, Four
Counter: VeHUNurse, Four
Counts Verified By: VeHUNurse, Three
Valid Consent/ID Band Confirmed By:
VeHUNurse, Four
Skin Prep By: VeHUNurse, Three
Skin Prep Agent: N/A
Dressing: TELFA, OP SITE
Preop Shave By: VeHUNurse, Three
Surgery Position(s):
Blood Loss: 200 ml
SUPINE
Urine Output: 1000 ml
Placed: N/A
Postoperative Mood: RELAXED
Restraints and Position Aids:
SAFETY STRAP
Electrocautery Unit:
Postoperative Consciousness: RESTING
Applied By: N/A
7299
ESU Coagulation Range:
N/A
Postoperative Skin Integrity: INTACT
Nursing Care Comments: NO COMMENTS ENTERED
.
.
.
Sponge Count:
YES
Sharps Count:
YES
Instrument Count: YES
Counter: VeHUNurse, Four
Counts Verified By: VeHUNurse, Three
Dressing: TELFA, OP SITE
Blood Loss: 200 ml
Urine Output: 1000 ml
Postoperative Mood: RELAXED
Postoperative Consciousness: RESTING
Postoperative Skin Integrity: INTACT
Nursing Care Comments: NO COMMENTS ENTERED
Signed by: es/ VeHUNurse, Four
VeHUNurse, Four 05/08/01 14:59
05/21/2004
11:37
ADDENDUM
The Count Verifier field was changed
from VeHUNurse, One
to VeHUNurse, Two
Signed by: es/ VeHUNurse, Four
VeHUNurse, Four 05/21/2004 11:37
Nurse Intraoperative Report
Addenda
Concurrent Cases
Additional References
Documentation including User, Technical
Manuals and Release Notes can be found
on the Electronic Signature for Operative
Reports VDL Web page.
http://www.va.gov/vdl/Clinical.asp?appID=103
Surgery Electronic Signature
for Operative Reports
Scott Ridings
Overview
•
•
•
•
TIU
ASU
Surgery Tab within CPRS GUI
508 Compliance Features
TIU
Text Integrated Utilities
TIU
This is where Reports,
Discharge Summaries and
Progress Notes are stored
and maintained.
What role does TIU play in the
Electronic Signature for Operative
Reports?
Answer:
This is where all Operative Reports
will be stored.
Specifically File 8925.
What role does the Clinical
Applications Coordinator and
Surgery ADPAC have with the
Installation of the TIU portion of the
Electronic Signature for Operative
Reports?
ANSWER:
You will need to work together as a
TEAM to complete the PreInstallation Worksheet.
Why is this so Critical?
Because your decisions reflect the
policies and practices of your
hospital.
TIU*1.0*112
Surgical Reports as a Coordinate
Class.
Clinical Documents
CLINICAL DOCUMENTS
CL
+ADDENDUM
DC
+DISCHARGE SUMMARY
CL
+PROGRESS NOTES
CL
- SURGICAL REPORTS
CL
OPERATION REPORTS
DC
OPERATION REPORT
TL
NURSE INTRAOPERATIVE REPORTS
DC
NURSE INTRAOPERATIVE REPORT TL
ANESTHESIA REPORTS
DC
ANESTHESIA REPORT
TL
PROCEDURE REPORT (NON-O.R.)
DC
PROCEDURE REPORT
TL
The Surgical Reports will be
activated upon Installation
The reports won’t be usable until
implementation of SR*3.0*100
What functionality will be used to
control and restrict access to the
Surgery Documents within TIU and
CPRS ?
Answer:
Authorization Subscription Utility
(ASU)
No TIU Business Rules will be
exported with TIU*1.0*112.
Sites will need to devise their own
policies.
Surgery Tab
CPRS GUI
CPRS GUI
A Surgery tab was developed to support the display
and management of Surgery report documents.
The layout and functionality of the tab was modeled
after the Consults tab.
CPRS GUI
The Surgery tab can be suppressed for those sites
not using the package.
Parameter: ORWOR SHOW SURGERY TAB
This parameter can be set at the following levels…
User, Service, Division, System and Package
CPRS GUI
Surgery Tab
All Surgery documents will display from this tab.
Unsigned Operation and Procedure
(Non-OR) Reports
• Functionality will provide the ability to:
•
•
•
•
Display
Print
Edit
Electronically Sign
Signed/Completed Operation and
Procedure (Non-OR) Reports
• Functionality will provide the ability to:
• Display
• Print
Addenda for Signed/Completed
Operation and Procedure (Non-OR)
Reports
•Functionality will provide the ability to:
•Create
•Display
•Print
•Edit
•Electronically Sign
Nurse Intraoperative and Anesthesia
Reports
•Functionality will provide the ability to:
•Display
•Print
85
508 Compliance feature
“N” and “O” on folders
CPRS GUI Version
GUI Version 23 is compatible with the New
Electronic Signature for Operative Reports
functionality
SR*3.0*128 & TIU*1.0*187
• Developed to address problems with
patches SR*3.0*100 and TIU*1.0*112
• SR*3*128 is released
• TIU*1*112 is in the testing phase and
should be released shortly
The Installation Guide
Worksheet
FAQs
• We’re a Cache site and during installation I’m
receiving an error <PROTECT>61+1^DIU0
– You will need to change the protection on the global. This is
done differently on Cache
– S X=$ZU(68,28,0) before installation
– Continue with installation
• How far back should I go to enter a date for
electronically signing converted reports?
– Recommendation is date of installation or you will need to reupload previously uploaded documents
FAQs cont.
• Can I add addenda to historical cases
(converted, but not e/s)?
– Yes, they will need to be e/s
• What is the approach for direct entry, is it
different than uploading?
– Once the stub is created in TIU, after TIME PAT OUT Of OR is
entered, the surgeon can find the stub in TIU and enter the text
operation report directly into CPRS
FAQs
• Will I be able to get the Operative Reports
in Health Summary and RDV?
– Patch GMTS*2.7*57 will enable access to
these reports
Questions ?