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Antibiotic Documentation in Docusys.cumentation in Docusys and ORCA Addendum's Correctio

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 given
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: http://depts.washington.edu/anesth/uwnetid/anesthonly/protocols/ORCA.pdf

    When making an ORCA addendum for a missed documentation of an antibiotic drug, please document
    the drug name, administration date/time, administration route, dose amount and dose unit.

REMINDERS:

    - Make sure you document the specific antibiotic drug if you select options (1) and (2) in the
      Antibiotic Note. Daily Docusys email reminders are sent out to the first
    - Attending/CRNA/Resident if there is missing documentation. Make ORCA addendums to
      correct this.
    - If Antibiotic drug information is entered retrospectively, remember to edit the time to reflect the
      correct administration time.