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VA IR

Guide to Documenting and Ordering

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Useful Door Codes

  • Staff Lounge: 31020
    • Microwave, Fridge, WC

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  • CT room: 35281

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  • IR control room: 97531

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Daily Work

  • ALL PATIENTS
    • Consent
    • Pre-procedure note
    • Order pre-meds for procedure: antibiotics, albumin, etc.
    • Post-procedure note (consult update)
    • Order meds used in procedure: sedation, heparin, tpa (alteplase), Benadryl, etc.

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  • OUTPATIENTS (In addition to above)
      • Pre-surgery order sets
      • Post-surgery order sets
      • Discharge instructions
      • Some patients may require overnight admission for observation (Check Amion for VA MAR)
        • Check Amion for VA MAR and present the case
        • Sign out to admitting team
        • Round on patient
      • Special cases:
        • Liver bland embolization has its own pre and post order sets

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  • The process for APPROVING CONSULTS it taped to the wall
    • Follow instructions and hand the paper consult to nurse for scheduling

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  • Look at prior images, discuss with attending, call referrers, do what you gotta do to get things rolling !

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  • Before you start rotation, make sure you have
    • ID and ID pin number
    • Signature Code
    • Pharmacy Code (Get from Basement level)

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Consenting

Tools > iMedConsent > Interventional Radiology > Consents-Basic > choose procedure

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Pre-Procedure Note

New Note > Pick the Date/Location > Type “Rad” and choose “PRE-PROCEDURE NOTE”

This is done for ALL INpatients and OUTpatients

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Post-Procedure Note/Consult Completion

This is done for ALL INpatients and OUTpatients

Go to Consults > Make sure you are on the IR consult > Action > Consult Results > Complete/Update Results

You can follow template, but I just cancel out and free-text the Post-Note

Post Note Basic Template:

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  • Procedure title
  • Operators
  • Meds
  • Complications
  • Procedure summary or any important details
  • Impression/Plan/things to follow-up on

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Discharge Instructions for OUTPATIENTS

This is done only for OUTPATIENTS that will be discharged through ambulatory surgery

Go to Notes > New Note > Type “Disch” and look for SURG: DISCHARGE INSTRUCTIONS > Fill out the form

Include instructions for patients, like keep dressings dry, may remove at X time. Or if patient went home with ThoraVent etc etc

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- This avoids you getting called b/c patient is confused

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OUTPATIENT order sets (pre and post)

Orders > ORDER SETS (BK) > BK Ambulatory Surgery Pre Op // Post Op Orders > Fill out forms

If you don’t have the ORDER SETS (BK) tab

- Call IRM and tell them to add it

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Special Order sets (like for UFE’s, Bland embos)

Orders > ORDER SETS (BK) > Under Interventional Radiology > IR Orders > Complete the orders

Admit patient to Medicine Observation/Med Obs > Call the VA MAR (Amion) to present case

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Ordering Meds (sedation, antibiotics, albumin etc)

Orders > MEDS:INPATIENT > ALL INPATIENT MEDSICATIONS > ALL INPATIENT MEDS > Free Type the Drug

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Ordering pathology and cytology

Orders > LAB: INPT WARD COLLECT > PATHOLOGY REQUEST > PATHOLOGY REQUEST > Fill out the form.

Use CYTOPATHOLOGY NON GYN REQUESTS for thyroid FNAs

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Ordering OUTPATIENT labs and COVID

COVID: Orders > LAB: OUTPATIENT DRAW > TODAY Only > Microbiology menu > Covid 19 > Covid 19 and FLU/RSV Screening Panel

For Bloodwork (CBC, CMP< PT/PTT/INR) you can go to > For All OTHER collection dates click here and change date > choose the date you need them

You can also just do it through TODAY only, but make sure to change the date

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COVID

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Bloodwork