Pre-Procedure Documentation

1. Pre-Procedure Documentation • Reason for the need to change • Variety of wrong patient, wrong procedure, wrong site events causing permanent harm to patients and many near misses, signaling a weak system • Most of the events involved procedural staff trying to make sense of incomplete information from the offices: consents missing, no last consult note, etc. • Most important, what has gotten lost has been the physician and patient original intention, confirmed in their office conversation about what was to be done

2. Current Process at CPAP(check for these items whether or not patient comes through CPAP) • CPAP looks into Allscripts for the following items: • Surgery Consent • Transfusion Consent • CPAP and/or PreOp Orders • Initial and/or Last Surgeon Office Visit Note • Any Outside Lab Work or Test Results • CPAP checks Allscripts at the following times: • Day Before the CPAP Visit • Day Before the Surgery

3. What they need from you • Items to be scanned into Allscripts 48 hours prior to CPAP appointment and/or OR date. • Consent Forms (approved Hospital Forms) and Order Sheets (approved Hospital Order Sheet) be scanned under the surgeon’s name that is performing the procedure. • If any of these items get scanned on the day prior to visit/surgery, please do one of the following: • Call CPAP, prior to 4:30, to make them aware of the new scanned item • Task it as a Go To Note to the BJ CPAP Chart Contents team, prior to 4:00. • Any unique or specific information should also be tasked to be printed for the Hospital chart.

4. Allscripts Update • Scanned document created Surgical Consent (scan) has been created and sorts to Surgery/Procedure Section of the chart. The goal is to make it easier for CPAP to find instead of looking through all of Consent (scan) documents. • To have this added to your Scan Chart Group please work with your Senior Analysts