JHH OR and Procedure Tracer

• Conducted on

  Date

• Unit Location

• Document No.

• MR No.

• Surgeon/Proceduralist
  Address

• Anesthesia Provider

• Staff Involved with Tracer

• Type of Anesthesia

• Procedure Name

• Patient Status: In-patient or Out-patient

• Admit Service

• Pre-documentation Identified: Yes or No

• If yes, type of pre-documentation evident in the chart: H&P Update Note, Immediate Post-Op Note or Other

• Prepared by

Record of Care

• All entries are signed, dated, and timed.<br>Providers must document ID# after signature.<br>Write legibly.<br>No prohibited abbreviation in the medical record.<br>Verbal orders are co-0signed within three calendar days<br><br> Include forms that are of clinical nature only (advance directive form, anesthesia pre-assessment, etc.) Do NOT include informed consents in this column (addressed later in the tool).

  Yes

  No

  N/A

H&P

• H&P completed no more than 30 days before or 24 hours after patient admission.

  Yes

  No

  N/A

H&P Update Note

• H&P Update Note by JHH Provider within 24 hours after admission and before surgery

  Yes

  No

  N/A

Pre-op Checklist

• Pre-procedure checklist present?

  Yes

  No

  N/A

Procedural Informed Consent

• Procedure informed consent completed, signed, witnessed, dated and timed before procedure

  Yes

  No

  N/A

• Procedural informed consent clearly documents the risks and benefits of the alternatives to the surgery

  Yes

  No

  N/A

Pre-Anesthesia Assessment

• Pre-anesthesia assessment contains following elements:<br>Heart<br>Lungs<br>Airway<br>ASA Classification<br>Review of medical history, including anesthesia, drug and allergy history<br>Plan of anesthesia care

  Yes

  No

  N/A

Anesthesia Informed Consent

• Anesthesia informed consent completed, signed, witnessed, dated and timed before procedure

  Yes

  No

  N/A

Nursing Intra/Post Procedure Note

• Intra-procedure <br>Post-Procedure<br>

  Yes

  No

  N/A

Site Marking

• Is the procedure site marked with the provider's initial?

  Yes

  No

  N/A

• Is site marked before the patient is moved to the procedure location?

  Yes

  No

  N/A

Time-Out/Universal Protocol

• Anesthesia Time-Out is documented prior to induction.

  Yes

  No

  N/A

• Time out is documented<br>- Correct patient identity<br>- Correct site<br>- Procedure to be done

  Yes

  No

  N/A

• Is the time-out conducted prior to starting procedure?

  Yes

  No

  N/A

Medication/Solution Labeling and Storage

• If not immediately administered, all medications are labeled with the medication name, strength, amount and diluent/volume (if not apparent from the container,

  Yes

  No

  N/A

• Propofol is clearly labeled with date and time medication was prepared in syringe. Note: Propofol must be administered within 6 hrs of preparation.

  Yes

  No

  N/A

• Multi-dose vials that are opened in immediate care areas (OR, patient or clinic room, or procedure room) are treated as single-use vial (used for only one patient) and discarded at the end of the procedure.

  Yes

  No

  N/A

• Nonscheduled medications are secured in a locked drawer, cart or Pyxis when the area is not under direct observation by authorized staff.

  Yes

  No

  N/A

Post-Anesthesia Eval

• Is post-anesthesia evaluation documentation present within 48 hours of the procedure?

  Yes

  No

  N/A

• Required elements documented no more than 48 hours post-procedure:<br>-Respiratory function (respiratory, airway patency, oxygen saturation)<br>-Cardiovascular function (pulse rate and blood pressure)<br>- Mental status<br>-Temperature<br>-Pain<br>-Nausea and vomiting<br>-Post- operative hydration

  Yes

  No

  N/A

Immediate Post-Op Note

• Is the immediate post-op note/brief op note present immediately after procedure and before transfer to PACU or sending unit?

  Yes

  No

  N/A

• Required elements documented immediately after procedure and before transfer to PACU or sending unit:<br>-Surgeon and assistant names<br>-Procedure performed<br>-Description of findings<br>-Pre-op diagnosis<br>-Post-op diagnosis<br>-Estimated blood loss<br>-Specimens removed

  Yes

  No

  N/A

Detailed Post-Op Note

• Is the detailed post-op note present and finalized within 7 days of post-procedure?

  Yes

  No

  N/A

• Required elements documented within 7 days post-procedure:<br>-All elements specified for immediate post-op note PLUS:<br>-Detailed description of procedure<br>-Clinical stage of tumor as appropriate

  Yes

  No

  N/A

Additional Documentation

• Home medication list completed

  Yes

  No

  N/A

• Discharge instructions documented

  Yes

  No

  N/A

• Home medication list updated, as appropriate

  Yes

  No

  N/A

• Advance Directives (AD) documentation completed

  Yes

  No

  N/A

Additional Areas:

• Laryngoscope blades are stored individually and are packaged in a clear bag or peel pack.

  Yes

  No

  N/A

• Laryngoscope blades removed from the bag or peel pack, available for use on an anesthesia cart or in a procedure room, are covered with a blue towel prior to the scheduled procedure. Note: Only one laryngoscope maybe placed on cart in preparation of immediate case and must be covered.

  Yes

  No

  N/A