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From the Surgeries and Procedures card, users can review and document the patient's surgical and procedure history.

 

The Review icon to the right of the card title allows the user to document that the Surgeries and Procedures card has been reviewed and no new information is needed or has been edited. To document that no changes are needed, select the icon and select No changes. The user’s name along with the date/time will display above the No changes option as the user who last reviewed the card.

 

The appearance of the Review icon will change as follows based on the review activity.

• : A green icon with a check mark indicates that the logged-in user was the individual who last reviewed the information within the Surgeries and Procedures card for this patient visit.

•: A green icon with initials will display when the last reviewer is someone other than the logged-in user.

•: An orange icon with a U indicates the information has never been reviewed.

•: An orange icon with initials will display when the last reviewer is someone other than the logged-in user on a previous visit.

•: An orange icon with a check mark will display when the logged-in user reviewed the Surgeries and Procedures card on a previous visit.

 

Surgeries and procedures can be sorted by date or in alphabetical order by selecting the Filter (cog) icon . When sorted alphabetically, procedures that display more than once will automatically sort by date, with the most recent procedure date displaying first.

 

If a patient has no known surgical history, a check box labeled No Known Procedures will display. Selecting this check box will indicate that the patient's history is up to date and there are no known procedures to add.

 

 

To View Attached Documents

When a procedure has a document attached, the Document icon will display. Select this icon to view the document, swap it, or remove it from the card. Once selected, the title "Attached files for (procedure name)" will display along with the title of the attached document and date of the procedure. The following options are available:

•: Displays the document in the Document Viewer. The document can be printed from the viewer. Selecting the Exit icon or back arrow will close the Document Viewer.

•: Allows the document to be swapped for another document. The Document Viewer will display with the current document in the Viewing Document field. Search for a new document using the Search Document field. Once you locate the appropriate document, select it and choose Select Document to attach it to the procedure.

•:  Removes the document from the procedure. A "Remove Document?" confirmation prompt will display. Select Yes to remove the document from the procedure or select No to keep the document attached to the procedure.

 

 

To Edit Procedures

Existing procedures can be edited by hovering over the procedure name and selecting the Edit icon. This opens the Procedures screen, where the user can make any necessary changes to the selected procedure. (NOTE: To edit a procedure, use the same process explained below for adding a new procedure.)

 

 

To Add a New Procedure or Surgery

 

1.Select the Add or Edit button on the Surgeries and Procedures card.

 

2.In the Add Surgery or Procedure search field, start typing the procedure name. This is a smart text field that will begin showing HLI lookup results after at least two characters have been entered.

 

3.Enter the surgery/procedure date in the date field or select it using the calendar icon. If using the icon, select the month and year, then select the day. The patient's age will auto-calculate in the following field once the date of the procedure has been selected.

 

4.To associate documents to the procedure, select the Attach Document icon; then select the appropriate document from the Document Viewer list. The Document Viewer will display documents from the following areas: Notes, Documentation, Documents, Documentation Reports, PhysDoc Documents, Order Entry Report (Radiology and Lab), Medical Record Documents, and Electronic File Management. A document can be attached or removed from a procedure at any time. Once a document has been associated with a procedure, it may be viewed from the summary view of the card or from within the details view as described above.

 

5.Select the Save button to add the new procedure to the listing.

 

 

To Remove a Procedure

 

To remove a procedure, select the Expand (chevron) icon to the left of the procedure name; then select the Delete icon (the red "x").