13.0 Correcting Anesthesia Encounters Flashcards
Why are ANESTHESIA RECORDS UNIQUE?
Anesthesia record is unique because Anesthesia does not exist by itself. Anesthesiologists don’t perform anesthesia without an associated procedure, information comprising the Anesthesia record comes from a variety of sources.
What is associated with ANESTHESIA EPISODES?
- Anesthesia
- Anesthesia Event
- Procedure
- Hospital Encounters (sort of)
What is an ANESTHESIA EPISODE record?
Also known as the HSB, this record serves as the nexus of all the documentation that could potentially take place on a patient in Epic Anesthesia.
INCLUDES: Anesthesia staffing, timing, links to other contacts, and more.
What is an ANESTHESIA record?
Also known as EPT contact type 52, this contact represents day‐of anesthesia documentation. The Intraprocedure anesthesia record is saved to this contact.
INCLUDES: Anesthesia events, One‐Step Meds, flowsheet documentation, and more.
What is an ANESTHESIA EVENT record?
Also known as EPT contact type 53, this contact represents the beginning of Anesthesia documentation, sometimes before the day of surgery. The pre/post Anesthesia record and all Anesthesia notes are saved to this contact.
INCLUDES: Pre‐evaluation note, post‐evaluation note, procedure/block notes, and more.
What is a HOSPITAL ENCOUNTER record?
Also known as EPT contact type 3, this contact is created by registration and is usually a Hospital Admission. It’s referenced by the Anesthesia Episode, but they aren’t linked.
INCLUDES: Admission date/time, location provider, discharge date/time, results, care plans, and more.
What is a PROCEDURE record?
This record/contact type varies based on the reason for the patient’s anesthetic.
INCLUDES: Log/case information, scheduled date and time, surgical staffing, and more.
What has to happen when Anesthesia providers choose the wrong procedure to document on?
You need to unlink those contacts and link the anesthesia record to the correct procedure.
What are the advantages of linking multiple procedures to one Anesthesia record from a navigator section?
Clinicians can see and manage all procedures linked to an anesthesia record in one place.
What can you organization do from the attached procedures navigator section?
- Link multiple procedures to a single anesthesia record.
- Allow any procedures linked to an anesthesia record to be unlinked.
- Move anesthesia information from one procedure to a different procedure.
- Display the appropriate procedure information from all linked procedures in one place.
- Provide a tool within the Anesthesia workspace for clinicians to link and unlink individual procedures from an anesthesia record
What happens when a PROECURE GETS HIGHLIGHTED IN RED?
The Anesthesia record is about to be unlinked from this procedure.
What do you have to do to save your changes?
Click Save & Close the Workspace.
What is the ANESTHESIA RECORD WIZARD?
Anesthesia Record Wizard allows Anesthesia administrators with the proper security to unlink Anesthesia documentation from a scheduled surgery or procedural appointment.
Can the Anesthesia Record Wizard can also delete Anesthesia records in addition to unlinking them?
Yes.
How is the Anesthesia Record Viewer accessed?
Through text.
What is NO ADD data?
Information that does not change between contacts, such as a patient’s birthday.
Explain Anesthesia Encounter Structure.
The Anesthesia Episode acts as a hub for all Anesthesia documentation. It is connected to the Anesthesia Event (which contains all notes written on the encounter), Anesthesia (which contains most Intraprocedure documentation), a procedure (and its associated documentation), and a Hospital Encounter.
What are the three most common mistakes in Anesthesia record documentation?
Documenting on the wrong patient, documenting on the wrong encounter, and having documentation split across multiple Anesthesia records.
What are some differences between the Attached Procedures Section and the Anesthesia Record Wizard?
The Attached Procedures Section is located within a Navigator and allows you to link or unlink multiple procedures simultaneously. The Anesthesia Record Wizard is a tool that requires a specific security point and allows you to unlink or unlink and delete an Anesthesia record.
What can you view using the Anesthesia Record Viewer?
All documentation related to an Anesthesia encounter.
What is the difference between Active records by patient and All records by patient?
Active records by patient only shows Anesthesia records that are open. All records by patient shows all Anesthesia records for a patient, included closed and deleted records.
When would you not see a surgery contact on an Anesthesia record?
If the Anesthesia record is an ad hoc procedure or is linked to an appointment.
