MetroHealth Department of Anesthesia Compurecord Information System

1. MetroHealth Department of Anesthesia Compurecord Information System • Who: All incoming/current Anesthesia residents, new/current Anesthesia attendings, new/current AA-C’s and CRNA’s • What: Basic explanation of practical/important points for using Compurecord in the OR • Why: Proper introduction of Compurecord to new anesthesia providers and refresher for current providers to assure proper documentation and timely billing and claims generation

2. CompuRecord provides a series of integrated modules... 1. Patient Evaluation 2. Case Browser 3. EZRecord 4. Insight 5. EZView 6. PACU Close 7. Quality Assurance Review 8. Drug Reports 9. Professional Charges Billing 10. Supplies Reports 11. Research 12. Management Information Services 13. Communications Gateway Interface

3. Most frequently used programs EZ record/PACU Close Intra-operative and post-operative record PAE – PreAnesthesia Evaluation Pre-Operative record Case Browser Data Repository of all Anesthesia Records

4. Compurecord Modules • EZ Record – in OR • PACU Close – Same as EZ record but used in PACU These are the icons you will see on the desktop

5. Compurecord Modules • PAE – PreAnesthesia Evaluation

6. Compurecord Modules • Case Browser – Review, edit or add to archived cases

7. Anyone can access these programs by either clicking on the icon on the desktop ORGoto – Start/Programs/Compurecord/EZRecord(or PAE or Case Browser)(This can be done even during the middle of a case)

8. Information Flow… • There are 3 main data groups that must be linked together for each patient; PAE INFO, INTRAOP INFO AND POSTOP INFO • In order to keep all information linked, the flow of information MUST BEGIN WITH PAE AND END WITH PACU CLOSE (Attendings should make every effort to use PAE and discontinue with the hand written epic sheet)

9. MHMC Peri-operative Workflow In Holding area at bedside – Use PAE application to begin flow By holding area nurse – info will flow to anesthesia forms automatically Completed in EPIC prior to surgery date Holding Notes Pre Surgical Evaluation Pre Anesthesia Evaluation Performed in Epic PACU OR PACU Close (looks like EZ Record) EZ record End Case ICU

10. First login of the day • Each computer in the OR should display the opened EZ record application, however occasionally the screen will show the desktop with a login screen (USE CTRL-ALT-DELETE TO BRING UP LOGIN SCREEN) • LOG IN WITH cruser/cr$user • (It may eventually change to individual network logon/pword)

11. STARTING A CASE… And so it begins………

12. DO NOT EVER PRE- ENTER A CASE IN THE OR! ! You can enter the same information (Case Info) by choosing your patient from the PAE /Holding area list.(Open the PAE Application – this can be done in OR or in Holding).If your patient was seen in the holding area (i.e. holding area nurses) they will be on the list and you

13. If your patient is not on the list, enter the MR# and they will show up if they were registered. Then choose FILE-ENTER FORM. When you see this screen, choose “Anesthesia Record” and it will allow you to fill in all the Case info for the patient. If the patient has been seen by holding area nurses, you will see their esig next to the label.

14. Lock = Login and Lock record – ALWAYS LOCK YOUR CASE WHEN NOT AT THE PC!! Page = Premade Comments B = Bolus Drugs I = Infusion Drugs Mask = Inhalational Gases Test Tube = Lab values IV Pole = IV fluids End of OR table with Foley bag = Outputs Monitor Screen = Edit/Review Vitals Magnifying Glass = Review case in text form OR table with light = Case Info Patient on Cart = PACU vitals ICON KEYS: These are the Icons most frequently used in the OR

15. Login – This will come up automatically or you can login manually by clicking on the “lock” icon at the top

16. You must choose a preload for the type of case you will be doing

17. Once you enter the OR, hit “Begin Record” to start the case. *NOTE: EVERYTIME YOU BEGIN A RECORD, A NEW PERMANENT FILE IS CREATED WHICH MUST BE USED

18. When you first identify a patient, choose the “case info” icon and you will see this screen – identify the patient by name or MRN #

19. If you have started the flow in the holding area by completing the PAE form, you will see your patient listed here. Choose and hit “OK”. If you do not see your patient, choose “new case”.

20. You will see a list of patients that have been Registered in the system. Choose your patient and hit “select patient”. DO NOT CHOOSE “NEW PATIENT” IF THEY ARE ALREADY LISTED. (You can choose “New Patient” if you do not see the patient on the list)

21. After selecting your patient you will see this screen - check the date and other pertinent info and then hit “select case”

22. PLEASE NOTIFY ONE OF US IF YOU NEED TO REIDENTIFY A PATIENT – YOU MAY POTENTIALLY ALTER PATIENT INFO!!

23. The “Event” key can be touched to cycle through: Begin Record, Induction, Surgery Start, Surgery Finish, Exit Room and End Case. If you “right click” on this key, you will see a list of all the events and you can return to a previous event if you skipped it by accident (just remember to delete it in the record) MINIMIZE USE OF THE SKIP KEY and if an event is skipped it must be added before ending the case!

24. The “Case info” key holds all the important clinical data for the case. This can be entered out in the holding area during the pre-anesthesia review or it can be done in the OR.

25. Attendings can Esig all the required items by hitting “Ctrl S” at any time during the case or they can go to the “case info” icon

26. At the end of the case YOU MUST HIT “END RECORD” BEFORE YOU LEAVE THE ROOM. FAILURE TO END THE CASE IN THE OR WILL DISALLOW THE CASE TO BE VIEWABLE IN PACU CLOSE!!!!

27. Complete the Record Complete all the required information – enter CPT and ICD9 codes if available– All codes are reviewed by the coder as this data is required for proper billing**

28. When you arrive in PACU, you will see a screen that looks similar ike the OR – hit “Continue Case” to see the list of patients from the OR.

29. *NOTE: IF YOU DO NOT END YOUR CASE IN THE OR, OR IF YOU DID NOT INITIALLY LOGIN CORRECTLY, YOU WILL NOT SEE YOUR PATIENT ON THE LIST

30. *******AIMS DO’s and DONT’s ******1) Never pre-enter a case2) Always select only one anesthesia technique and be sure the selection is correct.3) Always enter surgery start, surgery finish, and anesthesia or end time4) Always select the PAE entry in the or, do not ever start a new case when there is a PAE5) Always enter the correct surgeon – OB OR a must6) Never open a case already closed in PACU7) If a case is accidentally opened at the PACU Close workstation, do not panic simply enter the correct anesthesia finish time!8) Enter PAE on every case but be sure to select the Pae entry in the OR - this will keep all patient info intact

31. 9) If case is cancelled post PAE or Post OR ,document “case cancelled’ in the proposed procedure field in PAE or free text procedure field in EZRecord. • Always enter the proposed procedure in the pae • If case is cancelled all the required data must be entered in the EZ Record in order to charge • Always select the correct location • (FOR OB) When LPR rolls over to the next day, the paper record must have the start and end dates indicated with the correct time stamps 14) Always assure all required information has been entered: mrnn, patient name, encounter #, ASA, Surgeon, Attending Esig, anes technique, anes location, CPT and ICD9 when available, other cases data, trauma or emergency status.

32. REQUIRED INFORMATION FOR CORRECT BILLING • MRN • Encounter # • ASA • Emergency Case • Anesthesia Technique • Anesthesia Location • Primary Surgeon • Attending ESig • Other Cases Data • Patient Type • Anesthesia Start and Stop Time • CPT/ICD9 (if unknown will be entered by coder) ***Failure to provide this information will result in holding of all attending charges until required data is completed !!

33. CONTINGENCY PLAN FOR RUNNING EZ-RECORD CASES OFFLINE DURING ANY NETWORK / SERVER DOWNTIME The following steps need to be done for all CompuRecord client PCs to include CCP Main ORs, OB ORs & MASC ORs when the network is down or the server connection is disrupted due to the installation of a server patch….

34. 1. Click on File from the menu bar and select “Work Offline”. A message will prompt with a list of functions that will not be enabled. 2. Select “Yes” at the end of this message. 3. Start the case or continue working on a case already in progress. In the event of an extended network outage, at the start of each case the user will be prompted with the message “Warning you are currently working offline. Do you wish to reconnect to the network at this time?” Continue to select “No” until advised from IS support staff. 4. Once the server is back on the network, a message will prompt “Warning you are currently working offline. Do you wish to reconnect to the network at this time?” Select “Yes”

35. Please note that while the server/network is unavailable… • Cases can’t be continued from a PACU close workstation. Staff needs to enter PACU information from an OR workstation. • Anesthesia Records can’t be printed until the server is back on the network. The record will need to be printed once the server is back on line from Case Browser. • Patient search can’t be done and all patient info for new cases must be correctly entered e.g., the Patient Name, Encounter Number, MRN etc.

36. Cancelled Cases All cancelled cases are billable ! 1. Cancelled in Holding Enter “Case Cancelled” in the Procedure (free text) field in the PAE form. 2. Cancelled in OR Enter “Case Cancelled” in the Procedure (free text) field in the EZ Record form. Be sure to end the case even if cancelled. FYI-- You still need to complete all required information for billing- refer to previous slide.

37. Electronic Signature ALL RECORDS MUST BE ELECTRONICALLY SIGNED FOR BILLING TO PROCESS. HAND KEPT CASES MUST BE ELECTRONICALLY SIGNED FOR BILLING TO PROCESS. ALL RECORDS NEED TO BE ELECTRONICALLY SIGNED AS SOON AS POSSIBLE.

38. Questions – (Email or talk to TC) Thanks!!