AIMS Support Website
Constraints and Issues:
Responsibility of the Attending Anesthesiologist and the Anesthesia Care Giver:
Steps to handle documentation on the wrong patient:
Scenario 1: Wrong Pt. was detected at the time of "TIME OUT" or before OR less than 30-45 minutes has elapsed since the Anesthesia Start Time
Scenario 2: Wrong Pt. was detected at a later part of the case and significant data has been already entered.
· If significant amount of data has been captured or you have reached the end of the case, then the documentation will have to be converted into a paper anesthesia record. Notify Docusys team ASAP.
· Complete documentation in Docusys (though wrong patient name), but NEVER close the record in Docusys
· The Docusys Support Team will print the Docusys record for the wrong patient oncle documentation is complete (No outstanding missing required elements)
· The Anesthesia provider will manually correct the patient name, medical record number, age, procedure, diagnosis and other wrong data elements on all pages of the printed record.
· The Anesthesia provider will write the correct patient name, medical record number and encounter number on all pages (bottom left) of the printed record
· Anesthesia provider will write a comment related to why manual correction of the record was necessary and sign and date the comment.
· Docusys support team will make copies of the correct record and distribute it for billing.
· Docusys support team will submit the corrected record for manually scanned into ORCA
· If the record is already closed, the Docusys support team will notify ORCA team to remove the worng record
· Docusys support team will notify the CQI team of this incident.