PAIN
IN PSC, pain assessment is documented here.....
What is vital signs flowsheet?
The pre anesthesia evaluation is reviewed __________ times.
What is 3 times?
The patient is assessed pre-operatively in pre surgical testing and a Pre Anesthesia Evaluation is performed and documented by a NP. This can be seen in CIS.
Within 48 hours of surgery an attending Anesthesiologist will review the original evaluation and confirm the information by adding their signature, this can only be seen in EPIC.
The morning of surgery the Anesthesiologist reviews the assessment and confirms that there has been no changes in patient status. This is confirmed by the removal of the icon in Epic Grease Board.
Where can you find the History & Physical?
Chart review tab, under notes?
Where do you chart that interpreter services were utilized??
What is the flowsheet?
If you are unsure of an answer to something what are some of the things you can do?
These are included in the pain assessment on the flowsheet?
what is pain score, pain location, pain orientation, pain radiating, pain descriptors, pain frequency, effect of pain on daily activities, patient's states pain goal, pain interventions
JC surveyor says: show me the assessment of the patient by the surgeon on the day of surgery. what do you say?
You SAY:
H&P or Initial Consult valid up to 30 days prior to surgery, with a co-sign from surgeon and day of interval note from PA or surgeon.
Day of Surgery: S (surgeon ready icon) completes when site marking, consent and H&P are documented
Complete ______________ section in the Pre-procedure navigator to ensure all charting is complete.
What is verify?
The ______________ will be used to determine if patients meet criteria for discharge from the PACU.
Where can you find an emergency protocol in EPIC?
what is:
Find the patient in EPIC on the status board, click emergency protocols on the toolbar.
Critical events checklist in EPIC:
open patient chart, click sidebar summary, in the default surgery report, the first section is a link to the MSK Perioperative Critical Events Checklist. Click view PDF to open it.
The CPOT pain scale stands for.....
What is Critical Care Pain observation?
This icon completes when the PSC nurse documents pre-procedure complete.
What is P (preprocedure complete) icon?
Where in the chart can you find that the patient is HR for falls?
What is the story board?
For the modified Aldrete score, a score of ____ or greater qualifies the patient to be discharged.
What is 9?
what is the physicians first post op note and where can you find it?
Brief post op under notes tabs
If you give a patient IV pain medication, when should you re-assess for pain?
Where can you find the time out for the nerve block?
what is
Preprocedure tab, then timeout checklist
Where can you find a patients code status?
What is the story board?
How do you know if a patient on a clinical trial?
in patient chart on the story board
How do you obtain a translator?
MSKCC Language Assistance Program. Utilize unit based Martti” Wireless Translation Cart. use rover phone which have the propio translator app.
What should be included in the PACU flowsheet as part of the perioperative clinical documentation?
what is vital signs, pain score, pain relief effectiveness, and level of sedation
Where can you find the consent?
what is:
Chart reivew tab under media
Who can suspend the DNR/DNI when the patient goes to surgery?
Who is the surgeon or anesthesia?
How can you see if this patient had any procedures performed at the bedside?
under timeout
Who are your joint commission taskforce?
Nach, Mary, Monika, Eileen, Terri, Hashim