Retrospective Case Selection

Retrospective Case Selection
Case Selection
1
Case Selection
Step 1.
Launch SurgiNet
Mini Manual
1.
How to find your case retrospectively using Case
Selection
2.
Unfinalise a document
3.
Finalise a document
The Clinical Staff Selection window opens.
Step 7.
Enter the appropriate clinical staff details (for
example, Mead, Lucian).
SNSurgiNet Organiser opens with the following
icons showing.
Theatres’ Staff
Step 6.
Case Selection
Step 8.
Click Search.
Step 9.
The search results are returned.
The Case Selection view allows you to find patients booked
into surgery by case (booked by the primary procedure). It
provides a list of patients booked into the active location. The
list of patients can be filtered by the different options provided
in the Select By options.
Step 10. Select the required staff member and click OK.
From the toolbar at the top of the Case Selection pane, you
can check in patients. You can print, preview and sign
finalised documents for the selected patient. You can also
change the location for which the list shows.
Step 11. The Clin Staff field is complete.
Note: If there are multiple matches you can enter more detail
and click Search again.
Step 12. Click the From Date drop-down then select the
required date from the calendar.
Step 13. Enter the required date in the To Date field.
Note: It is possible to search for a case using different
criteria.
Step 14. Click Retrieve.
Step 15. A list is returned on the cases matching the search
terms.
Search by clinician
Step by Step Instructions
Support available through the following options:
1. Please contact your local Champion User
Step 16. The clinician’s cases for the entered date range
are displayed.
Step 2.
Within SurgiNet click Case Selection.
Step 3.
Select Clin Staff from the Select By options.
2. Theatres’ Surginet Team - Tel: 01225 82 5069
a.
Tel: 01225 82 5444
b.
Email: [email protected]
Step by Step Instructions
The Criteria changes.
3. Service Desk
Open a patient record
Step 17. Within the Case Selection screen select your
patient.
Note: It is possible to enter the clinician name directly within
the Clin Staff field. If there is a single match SurgiNet
will pull this through. If there multiple matches the field
will display a <<Multiple Matches>> message and you
must enter more detail to retrieve the correct clinician.
4. Self Service Call Logging via Intranet
Step 18. Open the patient record.
Note: Two ways of opening the patient record are:
Option 1. Double click the selected patient. This will take
you to the Patient Information pane within the
Step 5.
Click the Binoculars
icon.
Page 2
Date: 06/03/2012
Version: 2.0
Page 3
Author : Peter Goodchild
Unfinalise/Finalise
Unfinalise/Finalise
patient record.
Business Rules
The documentation segment is restored back to its last state.
Option 2. With the patient selected, select from the Record
menu the part of the patient record (for example,
Patient Information) that you wish to access.
The patient’s record opens.
Finalise a document
Scenario: The segments have been completed (green ticks
in all segments) and the document is now ready
to be finalised.
Close a patient record
Step 1.
Step 19. Select the X next to the patient name
Click the green flag - Finalise
The Document Verified dialog is displayed verifying that the
document has no deficits and can therefore be finalised.
Step 20. The patient’s record closes.
Step 2.
Exit SurgiNet
Step 21. To log out of SurgiNet, click Exit on the toolbar.
Step 22. The Exit Application dialog opens.
Click Yes to close the Document Verified dialog.
Note: If all the required fields are not completed, the
Documentation Deficits dialog opens. Double-click
the segment within the dialog to open the required
screen and complete all the mandatory fields.
Step 23. Select the Exit and shut down the application?
radio button then click Yes to close SurgiNet.
The Print Document dialog opens.
Step 24. SurgiNet closes.
Step 3.
2
icon .
Click Yes or No as appropriate.
Note: It is optional to print the finalised report at this stage. All
finalised documentation will be available to view and/or
print from the patient record Quick View, Record
View,Documentation and in PowerChart from Clinical
Notes tab.
Unfinalise / Finalise a Document
Unfinalising a document
Scenario: In the event of finalising in error or a
correction/amendment is required the
documentation can be unfinalised.
The document will open in the Preview pane.
Step 1.
Open a patient record and select Perioperative
Doc in tab menu.
Step 4.
Step 2.
Select the perioperative document to be
amended.
Step 5.
Select Task>Exit from the toolbar, or click
to close the patient’s record.
Result:
The documentation has been reviewed and
unfinalised. and finalised.
Step 3.
Click on the Un-finalise button
.
Check and review that all of the information is
correct.
Business Rules
1. All surgical trays, supplementaries and prepacks
should be recorded on the Instrument Tray
Details segment on the Intra Op Document using
a hand held barcode scanner.
2. All Loan Equipment should be recorded on the
Loan Equipment Details Segment on the Intra Op
Document.
3. The Op Note must be written up using
PowerChart/Millennium before the Patient leaves
the Theatre Complex, and it must record a
minimum of “Actual Procedure” and “Post Op
Instructions”.
4. The Op Note must be printed and attached to the
Patient Notes.
5. The PreOp, IntraOp and PostOp Summaries
must be printed, and a copy of each attached to
the Patient Notes, and a physical signature on
each paper document is mandatory.
6. The WHO Checklist must be completed for each
case.
7. All People present in Theatre must be recorded.
8. Timings should be documented accurately.
9. If a Surginet patient record is locked by another
member of Staff, it should only be unlocked with
agreement from the lock holder.
10. The preloading of patient data onto Surginet
should only happen while the patient is in the
Anesthetic Room and only when the procedure is
definitely going ahead.
11. Perioperative Documents must be finalised.
12. Every Patient episode in theatre must be
documented in Surginet.
The Unfinalise Document window appears
Step 4.
From the drop down select a reason for
unfinalising the document and add any supporting
notes in the Additional comments free text field.
Step 5.
Click OK
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