Sunday, March 19, 2017

Perioperative Prevention of Hypothermia, The Electronic Medical Record Version.

Electronic Medical Record (EMR) Documentation Design
1.     Develop an electronic questionnaire or SmartForm with assigned data (storage) elements that are available in the electronic medical record (EMR), to enable retrieval in a reportable form. Responses are in category lists, yes/no, or free text format.
2.     Data elements include:
a.     Preoperative care unit/holding area/emergency department/inpatient unit:
                                               i.     Patient temperature (category list of temperatures)
                                              ii.     Device category list:
·       Forced air warming (yes/no)
·       Warmed IV fluids (yes/no)
·       Inline IV fluid warmer (yes/no)
·       Other (yes/no; free text)
                                             iii.     Comments (free text to document unusual circumstances [eg, patient refusal with rationale, patient condition]; category list could be used if all responses can be complied)
b.     Intraoperative:
                                               i.     Device category list:
·       Forced-air warming (yes/no)
o   applied prior to anesthesia start (yes/no)
·       Warmed IV fluid (yes/no)
·       Inline IV fluid warmer (yes/no)
·       Other (yes/no; free text)
                                              ii.     Comments (free text to document unusual circumstances [eg, patient refusal with rationale, patient condition]; category list could be used if all responses can be complied)
c.     Postoperative:

                                               i.     Postop temperature (category list)

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