[MT-L] Start and stop time for anesthesia and surgery
Sonja London
We have a question as to what other facilities are doing regarding documentation of start and stop times of surgery and anesthesia. Who records the times. We do not have our ORM up and running at this time.
Sonja
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Jessica Bullock
Hello-
Our operative record is electronic but our anesthesia record is still on paper. The anesthesia provider and the circulator confirm that the procedure start and end times as well as the anesthesia start and end times coincide with one another. The circulator documents the times in the electronic record and anesthesia still documents the times on the paper record as well. We have time charges attached that are based on these start and stop times for both operative and anesthesia—in order for these charges to pass they must be entered into the electronic record. The anesthesia paper record is scanned into the system upon pt discharge. Hope this helps!
Jessica Bullock, RN
ORM Clinical Informatics Specialist/MIS
Lima Memorial Health System
1001 Bellefontaine Ave.
Lima, Ohio 45804
Phone (419)226-5197 ext. 4255
Fax (419)998-4725