CC-UC-01800 - Hospital: Basic Flow - Clinical Documentation After a Medical Procedure

Actors

• Client/client caregiver
• Medical Administrator
• Surgical team (may include; anesthesiologist, surgeon, operating room nurse(s), respiratory therapist etc.)

Pre-conditions

• The patient is at the hospital for a prescheduled procedure.
• The patient is covered by provincial/territorial health care insurance.
• The patient has given consent to receive the procedure.
• The surgical team has completed the medical procedure.

Step	Description	Data elements collected	Result
1	The surgical MD dictates operative notes.	Document Date and Time Document Status Document Principal Author Document Type Document Contributing Author Document Author Role Document Recipient Document Content	Operative notes are dictated and recorded in the patient's medical record in the hospital information system.
2	The clinical document is signed by an authorized clinician.	Not applicable	Clinical documents are signed by an authorized clinician, and details are recorded in the patient medical record in the hospital information system.
3	This use case ends.	Not applicable	Not applicable

Post-conditions

• Operative notes are dictated to document the completed medical procedure.
• Clinical documents are completed and signed by an authorized clinician.
• The patient's medical record is updated in the hospital information system.

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Contact us

If you have questions about this initiative, would like to be added to our stakeholder notification list or would like to participate in our consultations, please email us.

connectedcare@cihi.ca