The nurse is responsible for creating the Pre Procedure instructions for the patient.
The nurse will place a printed copy of the instructions on the front of the chart. As per current practice, the anesthesiologist will review. The pre-procedure meds are contained on page 1. In most cases, you will probably agree and give the instructions to the patient. If you need to edit, you can choose to document on the paper copy (or if preferred, electronically-to be discussed)
The nurse has been instructed to ask for an EPIC cosign for all patients being assessed by anesthesia. This means that we will still need to electronically sign the Pre-Procedure orders.
DO NOT SELECT
the Pre Procedure Instructions in the Evaluation section or you will end up creating a second set of instructions.
To view the instructions that have been documented by the nurse, select “
” in the left sidebar.
Go to Notes.
You will now see the note titled, “Preprocedure Instruc….” and that “
On the right, the “edit, copy, cosign and attest” options are available.
In the vast majority of cases, you will simply “Cosign”.
In the example below, you had told the patient to take the ascorbic acid on the morning of surgery.
You therefore need to Edit the note. Click “
Highlight the “
Hold morning of surgery
” and backspace to delete.
Free text the change you want to make and “
” the order,
If there many edits to the instructions and you would prefer to re-print for the patient, the following workflow applies.
Go to “Chart Review” and select the media tab. Make sure that NO filters are applied.
Select the “After Visits Summary” and the pdf of your new instructions should appear.
Hit the printer icon to re-print for the patient.