Procedure Timeout / Checklist — Ambulatory

 

On the Main Menu, click Settings > Clinicals. In the left menu, under Practice Links — Procedure Configuration, click Procedure Timeout / Checklist

 

 

Your organization must have the Structured Procedure Documentation feature enabled.

 

1. Display the Procedure Timeout / Checklist page: On the Main Menu, click Settings > Clinicals. In the left menu, under Practice Links — Procedure Configuration, click Procedure Timeout / Checklist.
2. Click add new.
   Additional fields appear.
   
3. Name — Enter an item for the checklist.
4. Click Save.
   The new procedure checklist item appears in the list of checklist items at the bottom of the page.
   Note: You can also edit and delete procedure checklist items.

 

athenahealth suggests starting with the following checklist items. Each checklist item is specific to stage of surgery (pre- or intra-op) and has configurable response options.

 

Pre-op

athenahealth suggests the following questions with Yes|No|N/A answer options:

 

Patient states (if able) full name?

Patient states (if able) date of birth?

Patient states (if able) planned procedure?

Patient states (if able) laterality?

Patient states (if able) allergies?

Responses match I.D. band?

Responses match consent?

Procedure site marked and initialed by provider?

Team member introductions completed by name and role?

Surgeon-specific concerns discussed?

Anesthesia-specific concerns discussed?

Nursing specific concerns discussed?

Patient-specific concerns discussed?

Risk of blood loss discussed?

Antibiotic prophylaxis discussed?

DVT prophylaxis discussed?

Essential equipment available and sterility confirmed?

Essential imaging displayed?

 

Intra-op

athenahealth suggests the following questions with Yes|No|N/A answer options:

 

Patient or responsible party states full name?

Patient or responsible party states date of birth?

Patient I.D. band verified?

Allergies reviewed?

Medication list reviewed?

Medical history reviewed?

Surgical history reviewed?

Beta-blocker last dose reviewed?

Anesthesia consent signed, verified, and in chart?

Surgical consent signed, verified, and in chart?

Blood product consent signed, verified, and in chart?

History and physical in chart and signed by physician within 30 days?

Preadmission testing results in chart and reviewed?

Imaging studies available?

Surgical site laterality / level verified?

Surgeon initials present at surgical site?

Patient ready for transport?

Stretcher / bed side rails up?

 

For pre-surgical evaluation (PAT)

For pre-surgical evaluation (PAT), athenahealth suggests the following questions with answer options listed below:

 

Scheduled procedure reviewed / confirmed with patient?

Yes|No

Allergies reviewed?

Yes

History of heart problems or chest pain?

Yes|No

Patient with pacemaker or defibrillator?

Yes|No

Taking a beta blocker currently?

Yes|No

History of lung problems?

Yes|No

History of sleep apnea?

Yes|No

Shortness of breath at rest?

Yes|No

Patient able to climb two flights of stairs without chest pain or shortness of breath?

Yes|No

History of strokes / TIAs?

Yes|No

History of diabetes?

Yes|No

History of bleeding or clotting problems?

Yes|No

Taking any blood thinning medications currently?

Yes|No

History of kidney disease or bladder problems?

Yes|No

History of liver problems?

Yes|No

History of acid reflux / heartburn / GERD?

Yes|No

History of thyroid problems?

Yes|No

History of neurologic problems (such as multiple sclerosis, dementia, Parkinson's disease)?

Yes|No

History of mood disorders such as depression?

Yes|No

History of cancer?

Yes|No

History of chronic steroid therapy?

Yes|No

Previous surgeries reviewed?

Yes|No|N/A

Any prior adverse reactions or complications related to anesthesia?

Yes|No|N/A

Any adverse reactions to anesthesia experienced by family member(s) (such as malignant hyperthermia)

Yes|No|N/A

Current medications reviewed and updated in chart?

Yes|No|N/A

If patient is female, any chance of current pregnancy?

Yes|No|N/A

If patient is female, currently breast feeding?

Yes|No|N/A

Chart updated with any relevant findings from questions above?

Yes|No|N/A

Spiecial accommodations for hearing, vision, or mobility impairments required?

Yes|No|N/A

Will patient require translator on day of surgery?

Yes|No|N/A

Reviewed pre-op teaching including NPO, meds start/stop, and any other special instructions?

Yes|No|N/A