Electronic Health Record Downtime Guidelines

o Change time to the actual time a task was completed on previously existing tasks that have completed but not documented on yet.

Anesthesia Providers:

▪ This section applies only to facilities that have implemented the Surgical Anesthesia Module. ▪ Anesthesia Providers document on paper when downtime occurs, even if the downtime ends during the time the patient is still in the operating room. ▪ The anesthesia record is scanned into the EHR. ▪ The registered nurse recovers only “Absolute Information” (See Appendix A for Absolute Information). ▪ General Information: The receiving nurse/nurse caring for the patient recovers “Absolute Information” (see Appendix A for “Absolute Information”) ▪ Provider Orders o All orders are to be recovered after downtime (see Appendix B for Order recovery) o Review and validate that all orders written during downtime have been transcribed. (RN) o Date/Time/Sign and indicate “EMR order recovery checked.” Rationale: Recovery of all orders, medications, and verifying requisitions written during downtime is essential to patient care and safety. Verifying this recovery indicates complete review. Wait for pharmacy to enter medications ordered during downtime and then document administration of medications when eMAR becomes available. ▪ Reconciling Medication Orders / Tasks o Enter the name of licensed clinician who administered the medication. o Enter the date and time of medication administered during downtime as noted on the paper MAR. o Complete the medication task, as indicated, for medications administered during downtime (including stop times). o Enter comment on medications recovered during downtime “See paper MAR .” ▪ Verify all medication orders generated during downtime interval with original written physician order and as entered into the eMAR by the pharmacy, with a second check, date, time, and signature on the original written physician order form. ▪ Notify pharmacy if downtime medication order is not entered into the eMAR during recovery period and re-send order if directed by the pharmacist. ▪ Patients discharged during downtime who received medications: o Write “Patient Discharged” on the MAR. o Send copy of paper Medication Administration Record (MAR) to the pharmacy. o Recover medications ordered and administered during downtime. Inpatient/Observation Care Areas: Medication Orders and Administration: ▪

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