Information

  • Conducted on

  • Unit Location

  • Document No.

  • MR No.

  • Surgeon/Proceduralist
  • 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).

H&P

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

H&P Update Note

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

Pre-op Checklist

  • Pre-procedure checklist present?

Procedural Informed Consent

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

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

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

Anesthesia Informed Consent

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

Nursing Intra/Post Procedure Note

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

Site Marking

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

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

Time-Out/Universal Protocol

  • Anesthesia Time-Out is documented prior to induction.

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

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

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,

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

  • 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.

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

Post-Anesthesia Eval

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

  • 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

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?

  • 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

Detailed Post-Op Note

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

  • 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

Additional Documentation

  • Home medication list completed

  • Discharge instructions documented

  • Home medication list updated, as appropriate

  • Advance Directives (AD) documentation completed

Additional Areas:

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

  • 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.

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