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Joy Pasternock EVS, HDS Scott Ridings EVS, HDS

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.

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Joy Pasternock EVS, HDS Scott Ridings EVS, HDS

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  1. Electronic Signature for Operative Reports Joy Pasternock EVS, HDS Scott Ridings EVS, HDS

  2. Objectives • Provide an Overview • Review Installation & Site Parameters • Review Signing Operative Reports

  3. Overview

  4. 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.

  5. Reports • Operation Report • Nurse Intraoperative Report • Anesthesia Report • Procedure Report (Non-O.R.)

  6. 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

  7. 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

  8. 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

  9. InstallationandSite Parameters

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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.

  15. 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

  16. 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

  17. 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

  18. 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.

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. Disclaimer • Shown when displaying reports for existing cases that have not been electronically signed • Alerts the reader that the information was not electronically signed

  26. 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.”

  27. 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

  28. Electronically Signing Operative Reports

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. Operation Report • After signature • Operation Report viewable on the Surgery tab to other users

  39. 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

  40. 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

  41. Nurse Intraoperative ReportRequired 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

  42. VeHUPatient, One (000-00-0001) MEDICAL RECORD NURSE INTRAOPERATIVE REPORT - CASE #000001 PAGE 1 Operating Room: WX OR3 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: FEB 12, 2004 07:55 Patient Out OR: FEB 12, 2004 12:15 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

  43. Nurse Intraoperative Report Functions • All information is reviewed & completed • Editing has been completed • “Sign the report” function

  44. 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>

  45. Signed Nurse Intraoperative Report • Moves into TIU files • Viewable on the Surgery tab

  46. Nurse Intraoperative ReportAddenda • Changes to information contained on the report require an electronically signed addendum • Created from any of the data entry options within the Surgery package

  47. Nurse Intraoperative ReportAddenda • 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

  48. Nurse Intraoperative ReportAddenda >>> 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.

  49. Nurse Intraoperative ReportAddenda • Exiting the data entry option • Second snapshot is taken • Compared with the original • Any changes create an addendum

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