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Documentation and Charting Errors

Documentation and Charting Errors. Jennifer Laux, RN, MSN, CNOR, Nurse Educator. Pros Standardizes Chart according to a care plan Outcomes Appropriate nomenclature (NIC, NOC, NANDA) Ability to retrieve data quickly. Cons Number of pages per segment. Pros and Cons of Surginet Charting.

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Documentation and Charting Errors

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  1. Documentation and Charting Errors Jennifer Laux, RN, MSN, CNOR, Nurse Educator

  2. Pros Standardizes Chart according to a care plan Outcomes Appropriate nomenclature (NIC, NOC, NANDA) Ability to retrieve data quickly Cons Number of pages per segment Pros and Cons of Surginet Charting

  3. Attempted Solutions • Pixel Count to change the page sizing. • Changes were attempted with resolution, however Surginet requires a specific resolution to function properly. • Removing the amount of content that is visible in the demographic banner, however this poses a patient safety issue as other departments utilize the demographic banner.

  4. Hiding the Patient Demographics Banner To hide the Patient Demographics Banner, go to • View • Demographic Banner • Hide and click on Hide.

  5. Retrieving the Patient Demographics Banner To retrieve the Patient Demographics Banner, go to • View • Demographic Banner • Hide and un-check Hide by clicking on it.

  6. Document Accuracy Dashboard

  7. Overlapping Cases in the Same Operating Room The portion of the Surginet charting that effects this section is specifically Cases that are documented as occurring in the same room at overlapping times as another case will be included. This error will be tracked at the site level only as we do not know which case is documented in the incorrect room and thus which SLM to assign the error to.

  8. Non-Finalized (by RN) Cases The portion of the Surginet charting that effects this section is Cases left unfinalized by an RN (not charge techs) will be included. We will run the Non-Finalized Documents report for opened documents only and will look at OR Nursing and Post Op document types. Errors will be assigned to SLM based on the specialty of the primary surgeon listed on the case.

  9. Surgeon Mismatch or Surgeon Discrepancy The portions of the Surginet charting that effect this section are specifically ~and~ specifically Cases where the primary surgeon documented in the procedure segment does not match the primary surgeon documented in the case attendee segment are counted as surgeon mismatch errors. Cases where the primary surgeon documented in the procedure segment or the case attendee segment is a resident, staff member, or other known non-surgeon are counted as surgeon errors.

  10. Anesthesia Type/Anesthesia Provider Mismatch or Missing The portions of the Surginet charting that effect this section are specifically ~and~ specifically Cases where the anesthesia type and anesthesia provider do not match (e.g., type = Local, and an anesthesiologist is documented or type = General and no anesthesiologist is documented), anesthesia type is documented as Other, or the default is not changed (e.g., from BLOR Anesthesiologist) are all counted as errors. Cases in patient rooms are excluded.

  11. Missing or Incorrect Circulator The portion of the Surginet charting that effects this section is specifically Cases where the first circulator in the Case Attendee segment is blank are counted as errors. Exception: Laser tattoo removal cases at Lake Drive Surgery Center. Cases where it is known the individual documented as the circulator is not an RN are counted as errors.

  12. Time Issues Cases where Set Up, Clean Up, Incision to Close or Patient out to Patient In durations are greater than 1440 minutes (24 hours) or equal to zero minutes are counted as errors. Times that are out of sequence are also considered to be errors.

  13. Procedures Documented with Possible or Versus The portion of the Surginet charting that effects this section is specifically Procedures that have possible or versus in actual procedure detail. NOTE: The modifier must be removed from both the BW Surgical Procedures section and from the primary procedure’sActual Procedure Detail text box.

  14. Total Occurrences Sum of all of the errors by site for the week, divided by the total errors for all of the sites.

  15. Tips and Tricks • Highlight the item/row you are on in each segment, this will populate the boxes below and you will be able to make sure components are filled and correct. • Utilize the button when recording times to assure sequential order of times. (i.e. incision is recorded as happening after the patient is in the room) • Hide the Patient Demographics to reduce the number of documentation pages.

  16. Questions?

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