Documentation of regional anesthesia and the process of clinical care in the WFU RAAPM area utilize a computer-based information management system which has been developed at WFU.
This system combines demographic data, information from scheduling, automated vital sign monitoring, and clinician-entered data to create a regional anesthesia procedure note which is design to dovetail with other AIMS documentation of perioperative clinical care, patient tracking, and billing activity.
The Regional AIMS document is a hybrid of an existing AIMS holding room document and an existing AIMS operating room document, but incorporates specific features to document regional anesthesia.
Roll over the Holding Room page to see a larger version.
The Holding Room page specifically documents the check-in process performed by the regional nurses and allows for initiation of automated vital sign collection. This document displays patient identification information in a floating icon upon the start of data entry which moves out of the way of the data entry cursor and disappears after 30 seconds.
Roll over the Universal Protocol page to see a larger version.
The Universal Protocol section allows for documentation of all steps completed for our well defined ‘time-out’ procedure. Steps one and two are used for documenting both time out verification in the OR prior to skin incision and a similar process of ‘time-out’ in the RAAPM Area prior to block needle placement.
Roll over Regional page and two to see a larger version.
Regional Page One and Two document the process of regional anesthesia. Page One allows documentation of the type of blocks performed with detail down to the manufacturer of the needle used. It is designed specifically to accommodate multiple blocks on one patient. The efficiency of data entry here is greatly dependent on the thoughtful and careful selection of default setting to reflect actual and ‘best’ practices at our institution. Regional Page Two is a direct adaptation of our intraoperative anesthesia document. Here automated vital signs are recorded while medications used for sedation and patient care is entered using a ‘clickable’ default template. Importantly, both page one and two allow for free text entry in cases when clinical care necessitates such documentation. Both these pages have been created to allow for accurate and easy documentation of regulatory and billing compliance.
Roll over the Attestation page to see a larger version.
Lastly, medical supervision of the regional anesthetic, day of surgery preoperative evaluation, and participation in the ‘time out’ procedure are documented by the anesthesiologist of record using the Attestation section of the record.
Because all the information collected above is accessible by network, John Galt AIMS is able to make use of this informa
tion in three important ways. First, patient census and block progress information is projected locally on two touch-screen monitors found in and just outside the regional area. Second, information about patient location is entered into the centralized operating room schedule remotely and electronically from the RAAPM area to assist providers in finding their patients. Thirdly, real-time patient vital sign data is sent and displayed on the computer monitor and television in the RAAPM workroom.
