26 Jul Anesthesia Documentation from MEDITECH
MEDITECH’s Solution for Anesthesia Documentation
Anesthesiology seems to be the most difficult discipline to bring on board to the electronic charting. It isn’t because they are being difficult, it’s because they are being diligent. Their job is to monitor the patient’s blood pressure, heart rhythm, temperature, level of consciousness, and amount of oxygen in the blood and the hemodynamic status of the patient. This can change at the drop of a hat. Therefore, to give a computer system to this specialized group of practitioners and say take your eyes off the monitors and the patients for just 3-5 minutes to figure out this new system is not acceptable. The words “It’s a difficult learning curve but once you have it, you will save time.” will not fly with this specialty.
MEDITECH recognizes that they needed something that will work for Anesthesia in their environment, and send the data to the electronic health record so that it is shared and desecrate data can be obtained from the intra-operative period. So MEDITECH teamed up with Spectrum Medical who is a leader in Profusion documentation to develop MEDITECH’s Anesthesia Interface Suite. This new Anesthesia Interface Suite is available for sites that are 6.15 release or greater.
We will go through a patient scenario. Patient Sam Sung is admitted for a Tonsil and Adenoidectomy. He presents to the same day surgery.
The nurse “Confirms” the Allergies and “Updates” the Med Reconciliation by entering the last take on all the home meds. Lastly the nurse gives a loading dose of Antibiotics. Naturally the nurse has done other documentation as well.
- Documents pre-eval in MEDITECH
- Logs into the Anesthesia Interface Suite (Spectrum) using the Viper tablet.
- Scan the patient’s wristband and their record comes up. All the documentation that the nurse documented is viewable. If Anesthesia needs to edit Allergies or Med Rec it is bi-directional, MEDITECH will be updated.
- Anesthesia chooses Intra-Op function
- They choose the medication that they pulled for the procedure. These medications are listed by class and are point and click.
- The monitor is on the screen recording the patient’s statistics.
- As the meds are given Anesthesia indicates so on the same screen as the monitor.
- At the end of the procedure all the documentation is done, except the Procedure, I/O, last set of vital signs and charges.
- If there were any events to note they can be entered retrospectively by clicking at the event time in the waveform and use canned text or free text; or a free text narrative is always available.
- Click Post Op for any post of documentation such as vital signs and level of consciousness.
The only unfavorable issue that I saw in my time with the system was that the medication documented in Spectrum did not flow back to the eMAR. This wasn’t so big for the normal Anesthesia meds but if the floor nurse is to continue antibiotic started in OR they will have to review the SUR chart and then notify pharmacy of when the next dose is due. MEDITECH is aware of this and has programming working with to resolve the problem.
To understand exactly what information is exchanged between MEDITECH and Spectrum please see the chart below:
Implementation can be a part of your 6x READY implementation or a separate implementation, it takes an estimated 4 months to implement.