start time when enter pt room, finish time is 1 hour after delivery
create a new iPro record, copy any pre-op consult into your chart. Chart the epidural under “regional” tab
if pt delivers when you are on shift, it is your responsibility to finalize the record
if handover to a colleague, use Provider tab to document handover times/people, suggest outgoing anaesthetist do this just before end of shift
remember to sign whole chart before handing over case
we can chart using the Notes function, the drugs section if we give something, and manually chart vitals if we do a top up
you don’t have to be continuously logged into pt record in iPro; the system will continue the case in the background until an End time is entered
C/S Without Epidural In-Situ
chart as we would in the main OR
Epidural Converting To Operative Delivery
For patients with EPIDURAL IN SITU COMING FOR URGENT C-SECTION, please use the previous anesthetic record that is open. DO NOT create a new record. Instead, add the C-section to the Procedure field under the “Patient” tab and create an event note or other documentation within iPro indicating your C-section start time.
Again, please do not create a new iPro record for those patients coming to OR with epidural ongoing – please use the same record. The epidural/spinal/CSE should be charted under “regional” and the intraoperative charting should be done under “Chart” tab. This practice creates unnecessary duplicate charts and makes it difficult to do retrospective audits.
suggest here that we finalize the record for the epidural and start a new record for the C/S (or instrumented delivery)
the history can by copied over so no need to repeat (previous record will appear in the Documents tab)
the rationale here is that 1) this is a separate event and billable to OHIP separately; 2) for QA purposes will be easier to track C/S at a later date; 3) you can apply a C/S template to speed charting in the new record, but can’t if the record continues as will erase the previously charted epidural
Covering Fellows
when you review the Fellow billing cards, which should appear in your box, this is the time to log into iPro, unlock that record and add the staff signature
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