ADOPTION OF BAR CODE SCANNING INTO THE ELECTRONIC MEDECAL RECORD AND THE ANESTHESIA INFORMATION MANAGEMENT SYSTEMS

Purpose:
The Electronic Medical Record (EMR) and Anesthesia Information Management systems (AIMS) in the PREOP, OR, and PACU have revolutionized patient documentation. Implementation of EMR and AIMS is steadily increasing. Barcode scanning has had an impact with regard to safety, compliance, and billing.

Significance:
Almost one-half of the 140 US academic anesthesia departments have already implemented or are currently searching for an AIMS. Barcode scanning has also has a significant impact with regard to quality improvement. Bar Code Scanning improves patient safety, and inventory control and billing charges.

Strategy and Implementation:
A pilot program was introduced in our ambulatory surgery center. Anesthesia provider log-in identification was barcoded and attached to the provider badge and utilized for accessing and documenting in the EMR/AIMS. The patients ID bracelet was modified to accept barcoding directly from the wristband and was then used for opening the correct patient's EMR/AIMS. This provided the Anesthesia Start time and the Anesthesia Timeout Procedure as specified by The Joint Commission (TJC) requirement. The Anesthesia time-out was adopted as a way of confirming the patient details and therefore aligned with the TJC requirement. This technique was then expanded to our nursing Preoperative Assessment (PREOP) and Post Anesthesia Care Unit (PACU), the main ORs and the Out-of-OR locations. The care-providers have their name and password encoded on a bar code matrix and this was used to open and sign doctors' orders, document anesthesia chart elements, and enter nursing PREOP and POSTOP evaluations.

Evaluation:
Implementation of the bar code scanning was started in the OR at the Ambulatory Care Center and expanded into the PREOP and PACU. This trial was so effective that it was adopted by the Main Anesthesia OR, Out-of-OR sites, PREOP and PACU. Additional uses include Lab Services for blood components.

Implications for Practice:
Barcode scanning has allowed for more comprehensive EMR/AIMS: enhancing patient safety and capturing appropriate charges, thus allowing the anesthesia and the nursing personnel to focus on patient care. Data has demonstrated a high rate of adoption within both the anesthesia and nursing departments.