PERIOPERATIVE MEANS PERIOPERATIVE.

Recordation’s Perioperative Information Management System provides individualized applications that document each of these critical steps in the perioperative process. The major areas and special procedures include:

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These individual modules interact with Recordation’s Core Software via wired or wireless connection to the Central Server, which stores and retrieves the perioperative data created by these modules, aggregates the information and analyzes it to create reports, and coordinates the communication of information from live individual worstations and users via a web-based portal.

PREOPERATIVE EVALUATION MODULE.

This stand-alone web-based application simplifies the collection of demographic, historical, physical information to optimize a patient’s preparation for an upcoming procedure. Recordation’s built-in two way communication software interfaces with a facility’s Information System via standard HL7 messaging to provide:

  1. demographic information such as Admission/Discharge/Transfer
  2. medication lists with dosages, frequencies of administration, last dose, etc.
  3. allergies
  4. laboratory values with live updates as values change
  5. electrocardiographic data
  6. radiologic data
  7. consultations

Recordation Preoperative Evaluation Module can function with or without access to a facility’s information system but still allows for facilitated manual entry of  demographic, medication, laboratory and other related information. This can be helpful when patients arrive for preoperative assessment with data from another facility’s information system.

PREOPERATIVE EVALUATION MODULE.

Users with tiered levels of medical knowledge can interact with patients and make individual, editable contributions to the preoperative record. In clinics with dedicated preoperative evaluation units, health care personnel can gather critical information prior to the anesthesia care team’s final preoperative contribution to verify the anesthetic plan and resuscitation status. Live updates to preoperative laboratory data are shown as flags for review.

PREOPERATIVE WALK-THROUGH CAROUSEL.

In this walk-through demonstration, fictitious patient Johnathan Cricket presents with shoulder arthrosis for arthroscopy on 9/10/2017.
ICD10 and CPT4 databases can be used for accurate coding of the diagnosis and procedure, or a free text description.
 
Elements of the Medical Review of Systems can be checked and described in detail.
 
Medication lists can be imported from the facility Health Information System or entered manually.
Previous surgical history and untoward reactions to anesthesia can be entered easily.
Social history can be used to document tobacco, alcohol and recreational drug use.
Substance allergies can be entered here.
Laboratory values can be obtained from the facility's Health Information System with one click, or can be entered manually.
 
Consultation results can be obtained from the facility's Health Information System or entered manually.
Elements of the anesthesia-focused physical examination can be entered here.
Flags or essential details can be entered for any element of the physical examination.
The anesthetic plan can be described in detail.
Physician or CRNA can review and complete the final note, as determined by Department Policy.

Recordation Preoperative Evaluation when accessed on a portable computer with secure wifi network (laptop or tablet), can serve as an ergonomic addition to the patient’s bedside interaction.

 

Physician or CRNA can review the final note, as determined by

RECORDATION INTRAOPERATIVE WORKSTATION

Recordation Intraoperative Workstation is used for the creation of intraoperative anesthetic records. Microsoft® Windows® based Touchscreen Tablets, Laptops, or dedicated Touchscreen/Computer combinations are dedicated to each anesthetizing location (operating room, for example). Instead of pen and paper, members of the anesthesia care team interact with the Recordation System via an intuitive Graphical User Interface (GUI) using gestures and button clicks, much like the use of a Smart Phone.

Typical interactions with the system easily documents the customary handwritten anesthetic interventions.

The user interface is designed to facilitate data entry, and rules are built into the system and can be configured based on the Department of Anesthesia and insurance practice patterns, such as Solo Anesthesiologist, Medical Direction of CRNA, and CRNA solo practice.

Documentation of commonly occurring events such as Airway Management, Regional Anesthetic Placement, Invasive Monitoring Line placement, are facilitated by the use of the Documentation Wizard, which provides a customized user-specific, simplified interface.

RECORDATION WORKSTATION Text.

 

This patient has entered the operating room, and an intravenous catheter is inserted. Vital signs are populating automatically, and oxygen, 2 liters per minute s applied.
A Propofol infusion is started at 180 microgram/kilogram/minute.
For Fresh Gases, Infusions, and Timers, the Total fresh gas, infusion dose and elapsed times are updated every second.
Induction of general anesthesia has occurred, and the patient has been intubated. Here, the vertical line indicates the time of induction.
The horizontal time scale has been changed from every minute to every five minutes for clarity.
The customized General Intubation template has been chosen for "one-click" induction documentation.
These medications will be placed on the anesthesia timeline for verification and if desired, edited or rearranged by sliding along the timeline.
Now the medications appear on the grid, and can be edited at any time.
The horizontal time scale is set back to one minute intervals for clarity.
Some time has passed, and isoflurane is administered, and inhaled and exhaled concentrations, along with minimal alveolar concentrations are seen in magenta and white, respectively.
Nitrous oxide and oxygen are administered at 2 liters per minute and 1 liter per minute, respectively.
Note the increase in minimal alveolar concentration (in white) without any change in isoflurane concentrations from the addition of nitrous oxide.
The horizontal time division is set to every five minutes for clarity.
These values have been chosen for a particular department.
Similarly, endotracheal intubation documentation can be loaded with typical values with the Load Defaults button.
These values have been chosen by a particular department of anesthesia.
A Main Menu facilitates the functions available in the system.
Here, the Glider Panel was selected. This is fully customized, and can be used to "slide" common interventions using the mouse or finger directly onto the timeline.
Here, "Calculate Inhalation Consumption" is selected, and will show, based upon instantaneous gas flow rates and inhalation agent concentrations, the total liquid anesthetic consumed thus far.
Based upon the fresh gas flow rates from the beginning of the anesthetic and the volatile anesthetic concentrations every second, approximately 3.3 ml of liquid isoflurane has been consumed.
 
Time advances to the left.
The horizontal time scale has been changed to fifteen minutes per vertical division.
Nearing the end of the surgical procedure.
The "End Procedure" button is pressed in real time, and can be adjusted as appropriate.
The system shows the procedure duration, which can be helpful to the operating room team.
The "Print Preview" button can be used to visualize the printable "Intraoperative Anesthesia Record" at any time. In this view, vital signs are set to average over five minute intervals.
Alternatively, this view show blood pressure values verbatim from the patient monitor.
Rules of Medical Direction and required Attestation Statements can be presented and authenticated at any time. The system can be configured for Solo Anesthesiologist or Solo CRNA, or for Medically Directed Anesthesiologist/CRNA, and will require the appropriate statements to be authenticated.
For at the end of the procedure, the "Complete Document" button is pressed, which enables the Checkout Manager. This function is customized by the Department of Anesthesia, and requests critical information elements prior to the closure of the document. For missing information, the "Help Me" button is clicked and brings up the appropriate elements, one at a time, for completion.
In this case, "Allergies and Adverse Reactions" can be completed.
Finally, a transfer of care from the Anesthesia Care Team to the Post Anesthesia Care Unit (or other destination) is made.
The final record is archived in the Recordation Central Server, and can be accessed via secure web browser with authentication, as a portable document format (PDF) file, with options such as Protected Health Information hidden (HIPAA compliant), Encrypted, with time resolutions from every thirty minute to every second intervals.