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A235_INCORRECT Patient (Documenting on the INCORRECT patient)

 

What should I do when I’ve documented in SIMS on the INCORRECT patient?

 

In order to prevent confusion, we’ve come up with two options.  The appropriate choice will be determined by two main factors:

1.       How long have you been documenting on the INCORRECT patient?

2.       Is there ample time to document on the CORRECT patient?

 

We have created a new event set titled, “A235_Incorrect Patient”.  Please follow the steps and complete the required fields for the option that has been chosen. It should be self explanatory when you look at the Event Set.

 

 

Option 1:< 15-30 minutes with adequate time to document on CORRECT patient

 

1.                  DELETE ALL EVENTS related to the case- multiple events can be chosen simultaneously by using the shift key, clicking on the first event and then clicking on the last event à all events between these two points will be highlighted

2.                  DELETE ALL ADMINISTERED DRUGS/FLUIDS

3.                  CONTACT

    1. SIMS Super User (working hours) notified and document name:

b.       System Admin (17808/78841) notified and document name: or leave message on voice mail-consider describing your plan

    1. Anesthesiologist (if relevant) scheduled for patient: that you are now documenting on

4.                  COMPLETE

    1. Incorrect Documentation started at:
    2. Incorrect Documentation ended at:

5.                  DO NOT ENTER FINISH TIME

6.                  DO NOT PRINT OR UPLOAD TO vOACIS

7.                  DO NOT DISCHARGE

8.                  TRANSFER Incorrect Patient

This will allow the correct patient to be charted on by the scheduled anesthesiologist PROVIDED the times do not overlap; i.e. if you are incorrectly charting on someone else’s patient, he/she will not be able to START  a session as that patient will be active on your machine and only visible to the scheduled anesthesiologist in Remote View

 

9.                  PLAN (use vital sign information from Vital Signs monitor for either a,b)

    1. Chart correct patient on PAPER
    2. START Session on correct patient (in this scenario, all vital signs and medications/fluids will have to be entered manually at the correct time OR entered as a Memo at the beginning of the case (hence the rationale for choosing this option if only minimal time has elapsed from case start)

Option 2:> 15-30 minutes and/or NO time to document on CORRECT patient

 

1.       DELETE ALL EVENTS related to the case- multiple events can be chosen simultaneously by using the shift key, clicking on the first event and then clicking on the last event à all events between these two points will be highlighted

2.       DELETE ALL ADMINISTERED DRUGS/FLUIDS

3.       CONTACT

    1. SIMS Super User (working hours) notified and document name:

b.       System Admin (17808/78841) notified and document name: or leave message on voice mail-consider describing your plan

    1. Anesthesiologist (if relevant) scheduled for patient: that you are now documenting on

4.       COMPLETE

    1. Incorrect Documentation started at:
    2. Incorrect Documentation ended at:

5.       DO NOT ENTER FINISH TIME

6.       DO NOT PRINT OR UPLOAD TO vOACIS

7.       DISCHARGE Incorrect Patient

Once discharged, this patient will NOT be available as per option 1 for the anesthesiologist of record.  Either the clerk will have to rebook the case or an SMS admission date will have to be chosen after entering the MRN of the patient using “Find”

 

8.       PLAN (use vital sign information from Vital Signs monitor)

    1. Chart correct patient on PAPER


Has a PREOP ASESSMENT been created in Preop Manager

 

Option 1: Has the chart been LOCKED?-YES (you will not be able to erase the MD Assessment, Anesthesia Plan, Tests and Results)

 

1.       ERASE documented Medications, Allergies and Precautions

2.       Add the following to the Addenda Section: “Medical History & Physical documented on WRONG patient”

3.       UPLOAD to vOACIS to overwrite original

4.       NOTIFY

    1. SIMS Super User (working hours) notified and document name:

b.       System Admin (17808/78841) notified and document name: or leave message on voice mail-consider describing your plan

5.       COMPLETE Preop Assessment on CORRECT patient

 

Option 2: Has the chart been LOCKED?-NO

1.       ERASE documented Medications, Allergies and Precautions

2.       ERASE ALL entries in MD Assessment

3.       ERASE ALL entries in Anesthesia Plan, Tests & Results, Record Status

4.       Upload to vOACIS to overwrite original (if required)

5.       COMPLETE Preop Assessment on CORRECT patient

 

 

 

 

 

 

 

 

 

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