Surgery area documentation tip sheet FINAL by HC121012041512

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									         AM Admits, OBV, Admissions from Day Surgery & ED
                           Where do physicians document?


AMA or OBV Patients
   H&P created prior to admission:
      If your patient is to be admitted to the hospital for an OBV or AMA and you dictate or
      handwrite the H&P in your office prior to the day of the patient’s surgery, it can be
      used as the admission H&P. In that case, you must enter a note in Epic referencing
      the location of the H&P and no changes, or any changes.
   H&P created at time of admission:
      If the H&P for an AMA or OBV patient is done at the time of admission it must be
        completed in Epic. This is due to the JCAHO requirement that the H&P be on the
        chart prior to surgery. To do this, locate the patient by using either Patient Station
        or the Ambulatory Surgery system list.

          To use Patient Station
          1.   Click the Patient Station button
          2.   Search for the patient by name (last name, first name) or MRN
          3.   Select the patient and click Accept
          4.   To show only the recent visits, on the toolbar select Recent.
          5.   Select the desired visit and click Accept
                   - Past visits display in gray
                   - Current visits display in green
                   - Future visits display in purple

          To open the Ambulatory Surgery System List:
          1.   Double-click the Outpatient System Lists folder.
          2.   Double-click either the Egleston–3 days or the Scottish Rite–3 days folder.
          3.   Select the Ambulatory Surgery list.
          4.   Open the patient’s chart and create your note.

Outpatient Surgery
   All outpatient surgery documentation will remain on paper.
   Once a decision is made to admit an outpatient surgery patient, progress notes,
    including the brief post-op note and discharge summary, should be completed in Epic.
    However, the paper H&P created for what was originally intended to be an outpatient
    surgery case does not need to be repeated in Epic. A note should be placed in Epic
    documenting the presence of a paper H&P on the chart.
   The H&P must be available to the clinical staff at the time of surgery. Dictated H&Ps
    must be done far enough in advance of surgery that a transcribed copy is available for
    surgery. Otherwise, the H&P must be done on paper.
Surgeon documentation that is out of scope for Epic:

   Operative reports must be dictated. The “Brief Post-op progress note” on the other hand
    must be entered into Epic and filed under the Progress Note tab. (That is, the Epic “note
    type” is a progress note, not a procedure note.)

   H&P for elective admissions for a scheduled procedure may be done on paper in the
    doctor’s office. This is to accommodate the workflow of the completion of the H&P in the
    doctor’s office prior to the scheduled procedure. In this case, a note should be entered
    into Epic referring to the presence of a paper H&P in the chart. It is also acceptable to do
    the entire H&P in Epic for elective admissions, but the patient’s Epic account is not
    available for charting until the time of admission.


ED Admit

   H&Ps may be entered into Epic for patients who remain in the ED while waiting for a
    room/bed assignment. To do this, locate the patient by using either Patient Station or the
    ED system list.

          To use Patient Station
          1.   Click the Patient Station button
          2.   Search for the patient by name (last name, first name) or MRN
          3.   Select the patient and click Accept
          4.   To show only the recent visits, on the toolbar select Recent.
          5.   Select the desired visit and click Accept
                   - Past visits display in gray
                   - Current visits display in green
                   - Future visits display in purple

          To open the ED System List:

          1. Double-click the Outpatient System Lists folder.
          2. Double-click either the Egleston–3 days or the Scottish Rite–3 days folder.
          3. Select the Emergency Depart list.
          4. Sort the list by patient name by clicking the Patient Name/Age/Sex column. If
             the patient has 2 visits for the same date, open the chart that has the highest
             Hospital Account #.
          5. Open the patient’s chart and create your note.

   The H&P for patients admitted from the ED must be completed in Epic or dictated.

   Direct admissions to the OR from ED must have an H&P available prior to surgery. This
    H&P must be completed in Epic.

   For emergent surgeries, JCAHO acknowledges the time constraints in creating a formal
    H&P. The Surgical ER Emergent H&P form is available in Epic to assist in basic
    documentation for emergency surgery admissions. The ED physician H&P may serve as
    supportive documentation, but the surgeon should enter appropriate summary
    documentation to support the decision for urgent surgery.

								
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