PAT
Which encounter is appropriate for documenting the PAT visit?
0110C-ANES-SVC Encounter from the Ambulatory Organizer.
What is the new report process for transferring an MSP patient to Preop?
1) The OR charge nurse will inform Preop charge that the MSP patient is ready for transfer.
2) The Preop charge nurse will contact the MSP charge nurse to get the primary nurse’s details.
3) Contact the primary nurse for report
How long does a patient need to be monitored in the PACU after receiving the last dose of naloxone or flumazenil?
60 minutes
After Implantable Collamer Lens (ICL) surgery, when should the patient have their first follow-up appointment?
in the afternoon on the day of surgery, for a pressure check.
If medication is not available in Pyxis, how can you request it without calling the inpatient pharmacy?
Go to MAR then right click the medication section. Select “Med request” and choose the reason then click “Submit” button.
What word must be included in your PAT document when the appointment is completed as a telephonic virtual visit?
"Telephone"
What are the required documents for patients undergoing surgery in Preop?
Surgical consent, anesthesia consent, universal protocol (228), H&P (within 30 days and updated within 24 hours prior to surgery), and the Pre surgery/procedure checklist.
How often should a patient’s vaginal bleeding and neuro-vascular status be assessed according to PACU SOP?
Admission, 30 mins x2 and then hourly, and discharge.
What is the minimum total observation period a patient must complete before being safely discharged home after receiving naloxone?
120 minutes from the time of the last naloxone dose
During the daily crash cart check, what test energy (Joules) should be used for the LifePak 15 defibrillator?
200 J
Where can you find your temporarily saved documents?
Form Browser
What is the current process for checking in a patient in Preop?
1) Click the check-in box from the case selection or double click the patient's name from the Periop tracking board list.
2) Click "modify" then select "Full DoD registration"
3) Document Bed Transfer to Preop room
4) Verify address
5) Click "complete"
What is the minimum duration a patient should be monitored following a postoperative rescue block?
20 Minutes
Within what time frame must discharge vital signs be obtained?
within 30 minutes of discharge
What is the indication for anesthesia to administer calcium chloride during surgery?
Anesthesia-induced hypotension.
What billing code needs to be placed in the order for a PAT encounter?
“s9445” PT EDUCATION NOC INDIVID
1) What is the current CRDAMC UHCG policy, and 2) is there a legal waiver available for UHCG?
1) Absence of menses for one year (menopause) AND 55 years or older, hysterectomy, bilateral salpingo-oophorectomy, and undergoing a D&C due to fetal demise.
2) No! We have a waiver-signing sheet, and it is not a legally binding document. Be sure to enter the appropriate documentation in the EHR.
What criteria must be met for PACU discharge of a patient after spinal anesthesia?
The patient must achieve a minimum dermatome level of T10, demonstrate gross motor movement in the legs, and meet all other discharge criteria, or as determined by the anesthesiologist.
What are the current postoperative fast-track policy guidelines?
1) Upon exit of the operating room, meet all of the PACU discharge criteria or as outlined by PONS SOP, whichever is more restrictive.
2) The patient must not have received any sedation (anxiolysis and/or pain medication) in the last 20 minutes of the case.
3) Excluding patients who received general anesthesia or a neuraxial block (spinal or epidural with local anesthetic).
When the Accu-Chek control solutions are expired, 1) where can you obtain replacements, and 2) what information must be included on the label?
1) PACU Pyxis or inpatient pharmacy. Select inventory then search "blood". You can find both the control solutions and the strips.
2) QC Controls label must have: Date opened (OP), Expiration date (EXP), and initials
List three locations where new diagnoses can be added?
1. In order details
2. Diagnoses and Problems on the Menu
3. Problem list from the DoD Preadmission Assessment
1) What is the standard procedure for initial T&C collection, and 2) how should you troubleshoot if a "lab session code" is required?
1) The sample must be collected within 72 hours by two nurses from two separate sites.
2) Write the names of the two nurses who collected the lab, along with the date and time, on the lab label.
List five goals of the PACU as outlined in the PACU SOP.
1) Ensuring a patent airway
2) Ensure a safe transition of the anesthetized patient to Phase II
3) Stabilize vital signs
4) Recognize and manage complications
5) Treat pain and nausea
Describe the appropriate change-of-shift report according to the SDS SOP.
1) IPASS report will be given individually to oncoming nurses promptly at start of shift, so as to enable continuity of care and an informed oncoming staff.
2) The oncoming charge nurse will be informed of situations of importance by the exiting charge nurse and by staff nurses as needed.
3) Assessments will be documented before leaving for the day, unless agreement is reached with the nurse assuming care of the patient ot perform and document the assessment.
1) What is the core five rights that ensure safe medication administration?
2) What is the required action following the omission or refusal of a scheduled medication?
1) Right patient, Right Drug, Right Dose, Right Route, Right Time.
Newer 7 rights: Right documentation, and Right Response.
2) Document "Not Done" in the MAR