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Here's how we streamlined our paperwork system. We paid a computer programmer about $600 to write a program for our electronic charting system that pulls information from certain fields on the electronic OR record to instantly create a separate post-op note. The post-op note includes all the JCAHO-required elements: surgeon, assistant surgeon, pre-op diagnosis, post-op diagnosis, procedure/findings and specimens. That way, the RN circulator only enters the information to the surgical record one time. The note prints on a dedicated printer in the dictation room (which has no traffic aside from surgeons and a unit clerk and is thus HIPAA compliant). By surgeon request, we also have fields for estimated blood loss, IV fluids used intraoperatively, drains and progress notes. The surgeons enter this information when reviewing the note, which is then signed and placed with the patient's chart.
Maureen Spangler RN, CNOR
writeMail("mdspangler@lexhealth.org")
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