Charting Challenge

During a Robotic Cholecystectomy, Isovue-300 is administered for a Cholangiogram.

Which med route should you chart?

On Page #3, the post-op diagnosis is always the same as the pre-op diagnosis.

If a patient meets Hcg testing criteria, but the test was not performed, you must chart the justification. At what age does Hcg testing for procedures begin? (type number only)

Since Anesthesia performed the TAP block, you don't have to chart the Exparel they used.

What pressure do you chart for lower leg SCDs?

You're entering 2 different procedure start/end times for a combo case.

Where is this documented?

An additional timeout needs to be documented when Anesthesia performs a TAP block.

An example of a correctly documented Actual Procedure (on Page #3) is "Hysteroscopy with Mirena IUD Insertion".

A delay code, including the number of minutes delayed if applicable, must be charted for every case.

There's nowhere else to chart an intra-op fingerstick glucose result, so it should be documented in nursing notes.

Your patient is getting 1 unit of FFP.

An additional, blood/blood product specific, ___________ must be documented.

During extubation, your patient has a laryngospasm, but thankfully recovers quickly. This should be documented as a Complication.

How many Intra-Op Packing (surgical site) Assessments should be entered for an average Robot Hyst?

Mesh is being soaked in NS prior to implantation. The lot # and expiration date from the bottle are charted on Page #4 by typing "Y" in the box next to the word ___________.