Electronic Signature for Operative

ReportsJoy Pasternock EVS, HDSScott Ridings EVS, HDS

ObjectivesObjectives

• Provide an Overview

• Review Installation & Site Parameters

• Review Signing Operative Reports

OverviewOverview

• Provides the ability to electronically sign operative reports contained within the VISTA Surgery application.

• Provides the ability to view these signed reports on the Surgery Tab in CPRS by storing them in the Text Integration Utilities (TIU) package.

Surgery Electronic Signature Enhancements

Surgery Electronic Signature Enhancements

ReportsReports

• Operation Report

• Nurse Intraoperative Report

• Anesthesia Report

• Procedure Report (Non-O.R.)

• Summaries are signed using the Surgery tab or TIU functions

• Cannot be signed using options within the Surgery package

• Surgeon is legally responsible for signing the dictated Operative Summary section of the Operation Report

Operation and Procedure (Non-O.R.) Reports

Operation and Procedure (Non-O.R.) Reports

Nurse Intraoperative Report and Anesthesia

Report

Nurse Intraoperative Report and Anesthesia

Report• Comprised primarily of information contained

in specific fields entered through the Surgery package as opposed to a dictated summary

• Signed using Surgery options only

• Cannot be signed directly from the Surgery Tab

• Uploaded into the TIU software upon signature– Viewable on the Surgery tab within CPRS

Nurse Intraoperative Report and Anesthesia Report

Addenda

Nurse Intraoperative Report and Anesthesia Report

Addenda

• Addenda for these reports are also created solely within Surgery options

• Controlling the process within Surgery options – Signed report and information contained

within the Surgery files remains the same

Installationand

Site Parameters

Installationand

Site Parameters

Installation of the Surgery Enhancement

Installation of the Surgery Enhancement

• Surgery patch (SR*3*100) provides the Electronic Signature for Operative Reports enhancements

• Prior to installing the patch, several setup issues need to be resolved

• The Text Integration Utilities patch TIU*1*112 must be installed prior to the Surgery patch (SR*3*100)

• The document definitions for the Operation Reports defined using the TIU options

Requirements Prior to Installation

Requirements Prior to Installation

Worksheet CompletionWorksheet Completion• Worksheet is provided with the Installation Guide

• Completed by the Surgery Application Coordinator with input– Clinical Application Coordinator– Other key Surgery staff

• Provide completed worksheet to IRM installer

• Do not install the Surgery patch without a completed worksheet

New Surgery ParameterNew Surgery Parameter

• Determine if your Medical Center Uses the Anesthesia Report

• New Parameter – ‘ANESTHESIA REPORT IN USE’

• Prompted during installation• Changed after installation

– Use the Surgery Package Management Menu

• Values– No – Default– Yes

Default Clinic for Documents

Default Clinic for Documents

• One of the new site parameters included with this patch is the DEFAULT CLINIC FOR DOCUMENTS parameter. – This non-count clinic will be the location passed to TIU, and is

used to establish an encounter when Surgery documents are created if no other location can be identified.

• Enter this parameter immediately following patch installation using the Surgery Site Parameters (Enter/Edit) option.

– Before entering this parameter, it may be necessary to create an active, non-count clinic in the HOSPITAL LOCATION file (#44), if a suitable one does not already exist.

• The default clinic will ensure that each surgery document will be linked to a clinic in the same division where the surgery occurred. – It is recommended that multidivisional facilities define a clinic for

each Surgery Site defined in the SURGERY SITE PARAMETERS file (#133) to ensure document linkage to the proper division.

Converting ReportsConverting Reports

• Identify existing cases that should be electronically signed using the new software

• Determine which reports for existing cases will be viewable through CPRS, but not electronically signed

• Update cases created with the Boston Class III software

Determine Existing Cases that should be signed using the New

Features

Determine Existing Cases that should be signed using the New

Features

• During installation

– Identify existing Surgery cases that will have reports electronically signed using the new features provided by the Electronic Signature for Operative Reports enhancement

Existing Cases Electronically Signed using

New Features

Existing Cases Electronically Signed using

New Features• All reports for all completed cases within

the date range selected are included – Case already has an uploaded surgeon’s

dictation– Signed paper copy of the Operation Report

• All associated operative reports will require electronic signature for that case

 

Enter the Starting Date for Reports to be signed electronically: 05/01/04

During the Post-Installation process, all reports for cases with an operation date on or after MAY 1, 2004 will be identified to be signed electronically.

 

Converting Reports

BenefitsBenefits• Convenience to users

– Ability to electronically sign vs. wet signature– Eliminates searching down paper copies

• Provides a practical medical record– Easier to locate reports

• Medical Record reviews• JCAHO visits

– Eliminates dual system

• Consistent method for signing & viewing reports similar to other TIU documents

DisadvantagesDisadvantages• Some Reports already signed on

paper will now also require an electronic signature

• Additional upload of previously authenticated documents

• Staff members may have left facility– Business Rules to allow COS or Service Chief

to sign

Making Reports for Existing Cases Viewable through

CPRS

Making Reports for Existing Cases Viewable through

CPRS• Determine beginning date to

include/view cases prior to installation• Consider the reports to include

– Operation Report– Nurse Intraoperative Report– Anesthesia Report– Procedure (non-or) Report

• Complete the Worksheet

Enter the Starting Date for Reports to be moved: 01/01/1995

Do you want to move the Operation Reports? NO// YES

Do you want to move the Nurse Intraoperative Reports? NO// YES

Do you want to move the Anesthesia Reports? NO// <Enter>

Do you want to move the Procedure(Non-O.R.)Reports? NO// <Enter>

During the Post-Installation process, the following reports will be moved for the date range January 1, 1995 through May 1, 2004:

Operation Report

Nurse Intraoperative Report

• New Option in Surgery Software– Make Reports Viewable in CPRS– Allows moving additional reports for

other date ranges after installation of the software

New Surgery Package Management Menu

Option

Make Reports Viewable In CPRS

Make Reports Viewable In CPRS

• CAUTION!! – This is a system intensive process that

creates new documents in TIU– Please ensure adequate disk space

availability before running this process. – Late activity messages may be

suppressed by disabling the mail group defined as the "Late Activity Mail Group" while this process runs. This mail group must be re-established after completion

DisclaimerDisclaimer

• Shown when displaying reports for existing cases that have not been electronically signed

• Alerts the reader that the information was not electronically signed

Disclaimer TextDisclaimer Text

• “This information is provided from historical files and cannot be verified that the author has authenticated/approved this information. The authenticated source document in the patient’s medical record should be reviewed to ensure that all information concerning this event has been reviewed or noted.”

Converting Reports Created with the Boston Class III

Software

Converting Reports Created with the Boston Class III

Software• Boston VA Class III Software

• Automatically converted to the new format during the installation of the Surgery patch

• Viewable through the Surgery tab and not Progress Notes

Electronically Signing Operative Reports

Electronically Signing Operative Reports

Signing/Editing Operative Reports

Signing/Editing Operative Reports

• Operation Report and Procedure Report (Non-O.R.)– CPRS GUI / Surgery Tab– TIU

• Nurse Intraoperative Report and Anesthesia Report– VistA Surgery Package

Procedure Report (Non-O.R. )

Procedure Report (Non-O.R. )

• New field added to the Edit Non-O.R. Procedure option– Determines whether a Procedure Summary gets

created for this specific case– Values

• No Entry (Null) - no summary will be created

• YES - the process for creating a summary will be similar to the Operation Report process explained in

the following slides

Operation ReportOperation Report• TIME PAT OUT OR

– Time patient leaves operating room – A stub entry for the Operation

Report is created within the TIU package

Stub

Operation Report Ready for Signature

Operation Report Ready for Signature

• Dictated & transcribed• Uploaded into TIU• TIU parameter settings determine when

view alert is sent to surgeon/attending– Release of documents– MAS Verification– Signature Requirements– Co-Signers

• Alert signals Operation Report is ready for signature

TIU ParametersTIU Parameters

• REQUIRE RELEASE:– Determines whether the person

entering the document is required (and prompted) to release the document from a draft state upon exit from the entry/editing process

– Values•No•Yes

TIU Parameters cont.TIU Parameters cont.

• REQUIRE MAS VERIFICATION:– Determines whether verification by MAS

is required, prior to public access and signature of the document

– Values• NO• YES, ALWAYS – Documents require verification

regardless how they originate• Upload Only – Require verification when documents

are uploaded• Direct Entry - Verification is required only when

documents are entered directly into VISTA

TIU Parameters Cont.TIU Parameters Cont.• REQUIRE AUTHOR TO SIGN:

– Indicates whether or not the author should sign the document before the expected cosigner (attending)

– Values• No

– Only the expected cosigner is alerted for signature– Unsigned document appears in the author's unsigned list, and

is ALLOWED to sign it, signature is not REQUIRED

• Yes– author is alerted for signature– If the expected cosigner should attempt to sign the document

first, they are informed that the author has not yet signed

TIU Parameters Cont.TIU Parameters Cont.

• SEND COSIGNATURE ALERT:– Controls the sequence in which alerts

are sent to the expected cosigner of a document

– Values• After Author has SIGNED• Immediately

Notification for the Operation Report

Notification for the Operation Report

• Displays the report is ready for signature

• Selecting the alert– Takes Surgeon to CPRS/Surgery tab

• The following slide display shows the unsigned Operation Report

Operation ReportOperation Report

• After signature– Operation Report viewable

on the Surgery tab to other users

Signing the Nurse Intraoperative Report and

Anesthesia Report

Signing the Nurse Intraoperative Report and

Anesthesia Report

•Process is the same– Uses data elements within Surgery

package

•Reports can only be signed within VistA Surgery functions

Notification to Sign Nurse Intraoperative Report

Notification to Sign Nurse Intraoperative Report

• TIME PAT OUT OR– The time the patient leaves the operating room is entered – Notification is sent to Circulating Nurse that the Nurse Intraoperative

Report is ready for signature

• Acting on the alert– Nurse taken to the Nurse Intraoperative Report option within the

Surgery package– Report Options

• Display• Print • Edit• Electronically sign

Nurse Intraoperative Report

Required Fields

Nurse Intraoperative Report

Required Fields• TIME PAT IN OR• TIME PAT OUT OR• Count Related Fields (if COUNTS

VERIFIED BY has been entered)• MARKED SITE CONFIRMED• PREOPERATIVE IMAGING CONFIRMED• TIME OUT VERIFIED

 

VeHUPatient, One (000-00-0001)

MEDICAL RECORD NURSE INTRAOPERATIVE REPORT - CASE #000001 PAGE 1

Operating Room: WX OR3 Surgical Priority: ELECTIVE

Patient in Hold: FEB 12, 2004 07:30 Patient in OR: FEB 12, 2004 08:00

Operation Begin: FEB 12, 2004 08:58 Operation End: FEB 12, 2004 12:10

Surgeon in OR: FEB 12, 2004 07:55 Patient Out OR: FEB 12, 2004 12:15

 

Major Operations Performed:

Primary: MVR

Other: ATRIAL SEPTAL DEFECT REPAIR

Other: TEE

Wound Classification: CLEAN

Operation Disposition: SICU

Discharged Via: ICU BED

  

Press <return> to continue, 'A' to access Nurse Intraoperative Report

functions, or '^' to exit: A

Nurse Intraoperative Report Functions

Nurse Intraoperative Report Functions

• All information is reviewed & completed

• Editing has been completed

• “Sign the report” function

Press <return> to continue, 'A' to access Nurse Intraoperative Report functions, or '^' to exit: A

VeHUPatient, One (000-00-0001) Case #000001 - MAY 1, 2004

Nurse Intraoperative Report Functions:

1. Edit report information

2. Print/View report from beginning

3. Sign the report

Select number: 3// <Enter>

Signed Nurse Intraoperative Report

• Moves into TIU files

• Viewable on the Surgery tab

Nurse Intraoperative ReportAddenda

Nurse Intraoperative ReportAddenda

•Changes to information contained on the report require an electronically signed addendum

•Created from any of the data entry options within the Surgery package

Nurse Intraoperative Report

Addenda

Nurse Intraoperative Report

Addenda• Entering the data entry option

– User is alerted that the report has been signed

• Snapshot of the current record is stored– In the background– Transparent to the user

>>> WARNING <<<

Electronically signed reports are associated with this case. Editing

of data that appear on electronically signed reports will require the

creation of addenda to the signed reports.

Nurse Intraoperative ReportAddenda

Nurse Intraoperative Report

Addenda

Nurse Intraoperative Report

Addenda•Exiting the data entry option

–Second snapshot is taken –Compared with the original

•Any changes create an addendum

VeHUPatient, One (000-00-0001) Case #000001 – MAY 1,2004

An addendum to each of the following electronically signed document(s) is required:

Nurse Intraoperative Report - Case # 000001

If you choose not to create an addendum, the original data will be restored

to the modified fields appearing on the signed reports.

Create addendum? YES// <Enter>

Addendum to Nurse Intraoperative Report for Case #000001 – MAY 1,2004

Patient: VeHUPatient, One (000-00-0001)

------------------------------------------------------------------------------------------------------

The Count Verifier field was changed

from VeHUNurse, One

to VeHUNurse, Two

Do you want to add a comment? YES// NO

Enter your Current Signature Code: XXXXX SIGNATURE VERIFIED

Nurse Intraoperative Report

Addenda

Nurse Intraoperative Report

Addenda

•The user elects not to sign the addendum– All changes made will be backed out– Restores the database to reflect what

was originally signed on the report

MEDICAL RECORD NURSE INTRAOPERATIVE REPORT PAGE 1

Case # 001

Operating Room: OR1 Surgical Priority: ELECTIVE

 

Patient in Hold: MAY 01, 2004 09:00 Patient in OR: MAY 01, 2004 09:30

Operation Begin: MAY 01, 2004 09:45 Operation End: MAY 01, 2004 12:30

Surgeon in OR: NOT ENTERED Patient Out OR: MAY 01, 2004 12:40

 

Major Operations Performed:

Primary: CHOLECYSTECTOMY

 

Wound Classification: CLEAN

Operation Disposition: PACU (RECOVERY ROOM)

Discharged Via: STRETCHER

 

Surgeon: VeHUProvider, One First Assist: VeHUNurse, One

Attend Surg: VeHUProvider, Two Second Assist: N/A

Anesthetist: VeHUProvider, Three Assistant Anesth: VeHUNurse, Two

 

OR Support Personnel:

Scrubbed Circulating

VeHUNurse, Three VeHUNurse, Four

 

Valid Consent/ID Band Confirmed By: VeHUNurse, Four

Skin Prep By: VeHUNurse, Three Skin Prep Agent: N/A

Preop Shave By: VeHUNurse, Three

Surgery Position(s):

SUPINE Placed: N/A

 

Restraints and Position Aids:

SAFETY STRAP Applied By: N/A

Electrocautery Unit: 7299

ESU Coagulation Range: N/A

ESU Cutting Range: N/A

Electroground Position(s): N/A

 

Tubes and Drains:

PENROSE, CYSTIC DUCT STUMP EXTERIORIZED TO LATERAL ABDOMINAL WALL

 

Medications:

DIAZEPAM 5MG/ML 2ML SYRINGE

Time Administered: MAY 01, 2004 09:55

Route: INTRAVENOUS Dosage: 10mg

Ordered By: VeHUProvider, One Admin By: VeHUNurse, Four

Comments: N/A

 

Irrigation Solution(s):

NORMAL SALINE

Time Used: MAY 01, 2001 10:05

Amount: 1000 Provider: VeHUProvider, One

 

Sponge Count: YES

Sharps Count: YES

Instrument Count: YES

Counter: VeHUNurse, Four

Counts Verified By: VeHUNurse, Three

 

Dressing: TELFA, OP SITE

 

Blood Loss: 200 ml Urine Output: 1000 ml

 

Postoperative Mood: RELAXED

Postoperative Consciousness: RESTING

Postoperative Skin Integrity: INTACT

 

Nursing Care Comments: NO COMMENTS ENTERED

.

.

.

Sponge Count: YES

Sharps Count: YES

Instrument Count: YES

Counter: VeHUNurse, Four

Counts Verified By: VeHUNurse, Three

 

Dressing: TELFA, OP SITE

 

Blood Loss: 200 ml Urine Output: 1000 ml

 

Postoperative Mood: RELAXED

Postoperative Consciousness: RESTING

Postoperative Skin Integrity: INTACT

 

Nursing Care Comments: NO COMMENTS ENTERED

Signed by: es/ VeHUNurse, Four

VeHUNurse, Four 05/08/01 14:59

05/21/2004 11:37 ADDENDUM

The Count Verifier field was changed

from VeHUNurse, One

to VeHUNurse, Two

Signed by: es/ VeHUNurse, Four

VeHUNurse, Four 05/21/2004 11:37

Nurse Intraoperative Report

Addenda

Nurse Intraoperative Report

Addenda

Concurrent Cases

Documentation including User, Technical Manuals and Release Notes can be found on the Electronic Signature for Operative Reports VDL Web page.

http://www.va.gov/vdl/Clinical.asp?appID=103

Additional ReferencesAdditional References

Surgery Electronic Signature for Operative

Reports

Surgery Electronic Signature for Operative

ReportsScott Ridings

OverviewOverview

• TIU• ASU• Surgery Tab within CPRS GUI• 508 Compliance Features

TIU

Text Integrated Utilities

TIU

Text Integrated Utilities

TIU

This is where Reports, Discharge Summaries and Progress Notes are stored

and maintained.

TIU

This is where Reports, Discharge Summaries and Progress Notes are stored

and maintained.

What role does TIU play in the Electronic Signature for

Operative Reports?

Answer:This is where all Operative

Reports will be stored.Specifically File 8925.

What role does TIU play in the Electronic Signature for

Operative Reports?

Answer:This is where all Operative

Reports will be stored.Specifically File 8925.

What role does the Clinical Applications Coordinator and Surgery ADPAC have with the

Installation of the TIU portion of the Electronic Signature for

Operative Reports?

What role does the Clinical Applications Coordinator and Surgery ADPAC have with the

Installation of the TIU portion of the Electronic Signature for

Operative Reports?

ANSWER:

You will need to work together as a TEAM to complete the Pre-

Installation Worksheet.

ANSWER:

You will need to work together as a TEAM to complete the Pre-

Installation Worksheet.

Why is this so Critical?

Because your decisions reflect the policies and practices of

your hospital.

Why is this so Critical?

Because your decisions reflect the policies and practices of

your hospital.

TIU*1.0*112TIU*1.0*112

Surgical Reports as a Coordinate Class.

Surgical Reports as a Coordinate Class.

CLINICAL DOCUMENTS CL +ADDENDUM DC +DISCHARGE SUMMARY CL +PROGRESS NOTES CL - SURGICAL REPORTS CL OPERATION REPORTS DC OPERATION REPORT TL NURSE INTRAOPERATIVE REPORTS DC NURSE INTRAOPERATIVE REPORT TL ANESTHESIA REPORTS DC ANESTHESIA REPORT TL PROCEDURE REPORT (NON-O.R.) DC PROCEDURE REPORT TL

CLINICAL DOCUMENTS CL +ADDENDUM DC +DISCHARGE SUMMARY CL +PROGRESS NOTES CL - SURGICAL REPORTS CL OPERATION REPORTS DC OPERATION REPORT TL NURSE INTRAOPERATIVE REPORTS DC NURSE INTRAOPERATIVE REPORT TL ANESTHESIA REPORTS DC ANESTHESIA REPORT TL PROCEDURE REPORT (NON-O.R.) DC PROCEDURE REPORT TL

Clinical Documents

The Surgical Reports will be activated upon Installation

The reports won’t be usable until implementation of

SR*3.0*100

The Surgical Reports will be activated upon Installation

The reports won’t be usable until implementation of

SR*3.0*100

What functionality will be used to control and restrict access to the Surgery Documents within

TIU and CPRS ?

Answer: Authorization Subscription Utility

(ASU)

What functionality will be used to control and restrict access to the Surgery Documents within

TIU and CPRS ?

Answer: Authorization Subscription Utility

(ASU)

No TIU Business Rules will be exported with TIU*1.0*112.

Sites will need to devise their own policies.

No TIU Business Rules will be exported with TIU*1.0*112.

Sites will need to devise their own policies.

Surgery Tab CPRS GUI

Surgery Tab CPRS GUI

CPRS GUI

A Surgery tab was developed to support the display and management of Surgery report

documents.

The layout and functionality of the tab was modeled after the Consults tab.

CPRS GUI

A Surgery tab was developed to support the display and management of Surgery report

documents.

The layout and functionality of the tab was modeled after the Consults tab.

CPRS GUI

The Surgery tab can be suppressed for those sites not using the package.

Parameter: ORWOR SHOW SURGERY TAB

This parameter can be set at the following levels…

User, Service, Division, System and Package

CPRS GUI

The Surgery tab can be suppressed for those sites not using the package.

Parameter: ORWOR SHOW SURGERY TAB

This parameter can be set at the following levels…

User, Service, Division, System and Package

CPRS GUI

Surgery Tab

All Surgery documents will display from this tab.

CPRS GUI

Surgery Tab

All Surgery documents will display from this tab.

• Functionality will provide the ability to:

• Display

• Print

• Edit

• Electronically Sign

Unsigned Operation and Procedure (Non-OR) Reports

Unsigned Operation and Procedure (Non-OR) Reports

• Functionality will provide the ability to:

• Display

• Print

Signed/Completed Operation and Procedure (Non-OR) Reports

Signed/Completed Operation and Procedure (Non-OR) Reports

•Functionality will provide the ability to:

•Create

•Display

•Print

•Edit

•Electronically Sign

Addenda for Signed/Completed Operation and Procedure (Non-

OR) Reports

Addenda for Signed/Completed Operation and Procedure (Non-

OR) Reports

•Functionality will provide the ability to:

•Display

•Print

Nurse Intraoperative and Anesthesia Reports

Nurse Intraoperative and Anesthesia Reports

8585

508 Compliance feature

“N” and “O” on folders

508 Compliance feature

“N” and “O” on folders

CPRS GUI Version

GUI Version 23 is compatible with the New Electronic Signature for Operative

Reports functionality

CPRS GUI Version

GUI Version 23 is compatible with the New Electronic Signature for Operative

Reports functionality

SR*3.0*128 & TIU*1.0*187SR*3.0*128 & TIU*1.0*187

• Developed to address problems with patches SR*3.0*100 and TIU*1.0*112

• SR*3*128 is released

• TIU*1*112 is in the testing phase and should be released shortly

The Installation Guide Worksheet

FAQsFAQs• We’re a Cache site and during installation I’m

receiving an error <PROTECT>61+1^DIU0– You will need to change the protection on the global. This is

done differently on Cache– S X=$ZU(68,28,0) before installation– Continue with installation

• How far back should I go to enter a date for electronically signing converted reports?– Recommendation is date of installation or you will need to

re-upload previously uploaded documents

FAQs cont.FAQs cont.

• Can I add addenda to historical cases (converted, but not e/s)?– Yes, they will need to be e/s

• What is the approach for direct entry, is it different than uploading?– Once the stub is created in TIU, after TIME PAT OUT Of

OR is entered, the surgeon can find the stub in TIU and enter the text operation report directly into CPRS

FAQsFAQs

• Will I be able to get the Operative Reports in Health Summary and RDV?– Patch GMTS*2.7*57 will enable access to

these reports

Questions ?Questions ?