Antibiotic Documentation in Docusys is
a two-step process. First, enter the Antibiotic Note,
describingwhat the antibiotic administration plan is and then
enter the specific antibiotic drug information, if applicable.
The time of the Antibiotic Drug
documentation is IMPORTANT as this time is used to evaluate
adherence to ON-TIME delivery. However, the time of the
Antibiotic Note itself is IRRELEVANT.
The Antibiotic Note has the following
options. Please see explanations for selecting them
Antibiotic given PRIOR to incision by the
Anesthesia Team. See drug List.
Select this option ONLY IF the Anesthesia Team
is responsible for administering antibiotic prior to incision
AND if the antibiotic administration plan is indeed to
administer the antibiotic prior to incision. If you select
this option and if the actual drug documentation is after
incision, the case will be counted against you.
FAILED to administer prior to incision by the Anesthesia
Team. See drug List.
This is an “admission of guilt” selection.
Select this option ONLY if the antibiotic was supposed to be
by the anesthesia team prior to incision per the administration
plan, BUT the anesthesia team FORGOT to
give it before incision. If you select this option and if the
actual drug documentation is after incision, the case
will be counted against you.
Antibiotic not given prior to incision for medical reasons
Select this option for all scenarios where an
antibiotic was either not given or given after incision for a
medical reason. Some scenarios include: Antibiotic given by
nursing prior to surgery, Antibiotic not available
in time and surgeon proceeded with incision, Antibiotic given
after incision because the clinical team was
waiting for specimen culture etc. If you select this option the
system will NOT count the case against you for
no antibiotic administration
Antibiotic not ordered
Select this option if the antibiotic was not
ordered for the case. If you select this option the system will
NOT count the case against you for no antibiotic administration.
Essentially this option is the same as
“Antibiotic not given prior to incision for medical reasons”.
If you make a documentation mistake, please
make an ORCA addendum to correct it.
For help with making ORCA addendums, please
follow the link: