Purpose: Creating surgeries in the system helps in tracking patient information, including medical history, current condition, and specific surgical needs. This ensures that all relevant data is available to the surgical team.
Proper documentation of surgeries is crucial for legal and regulatory compliance. It ensures that all procedures are recorded accurately, which is important for patient safety and legal purposes.
By documenting surgeries, healthcare facilities can analyze outcomes, identify areas for improvement, and implement changes to enhance the quality of care.
Application Role Required:
Inpatient_General
CaseManager
Follow the steps on how to create surgeries in Outpatient application:
On the patient file click 'Surgery' tab.
Click on '+ Surgery Schedule'.
Add the surgery date. Click 'Set Now' if it is starting on that moment.
Click on the surgery you created to start documenting.
If patient has arrived and ready for the procedure, click 'Arrived for Surgery'
Surgeries are documented as they progress. There are different tabs where different categories of data is documented during the surgery. These are:
Overview
A-Scan
Anesthesia
Labs & Diagnostics
Pre Op
Intra Op
Procedures
Follow-Up
Vitals
Medication
Quick add Med
Administered Medications
Time and Motion
OVERVIEW TAB
Click the pencil icon to start editing.
Summary Section
Surgery Date - Date and time of surgery.
Surgery Status - This documents the status of the surgery at that particular time.
Scheduled By - Enter the employee who scheduled the surgery.
Specialty - Enter employee Specialty
Surgeon - Enter the name of the surgeon who will be conducting the surgery.
Surgeon Exam Needed - Select if exam is needed.
Consent Section
For you to be able to sign consents, you need to add the procedure on the Procedure tab under Procedure Type.
Click the pencil icon on Consent Section and give the patient to read. If patient has understood and consented verbally click the 'Consent ready, continue to sign' button.
Make sure all required signees sign the consent and save.
You can preview the consent pdf by clicking the 'Preview' button.
A-SCAN TAB
The A-Scan photo will only show if it was taken from Eye general service.
If it was taken more than 6 months ago it won't show.
ANESTHESIA TAB
Plan Section -Decides whether to use general, regional, or local anesthesia based on the type of surgery and patient factors.
Provider Section - Select the name of the anesthesia provider.
Anesthesia Evaluation Section - Enter notes on observations made before anesthesia.
Pre Anesthesia Evaluation Final Check Section - Enter notes on observations made before anesthesia.
LAB & DIAGNOSTICS TAB
Add any lab and diagnostics orders the patients needs during surgery.
PRE OP CHECKLIST TAB
Enter notes for pre op- ensuring that patient examination is done and patient is ready for procedure.
If the patient is ready, click the Ready for surgery button.
INTRA OP TAB
Surgical Attendees Section
Attendee / Role - Add the names of people attending the surgery and their roles. Click 'Add' to add more attendees and save.
Time & Motion Section
Enter OR - Enter date and time when patient entered operation room. Click 'Now' if patient is entering at that particular time.
Left OR - Enter date and time when patient left the operation room. Click 'Now' if patient is entering at that particular time.
PROCEDURE TAB
Click '+ Surgery Procedure' button in order to create a new procedure.
Click on the surgery and start adding details:
Surgery Site - Enter the body part that is going to be operated.
Procedure Type - Enter the type of procedure to be done on the body part.
Procedure Consent Name - This is the procedure name that will show on the consent form. This field is auto-populated after entering procedure type.
Procedure Method - Enter the method that will be used for the procedure.
Procedure Status - Enter the status of the procedure at that particular time.
Surgery Priority - select if it's primary or secondary procedure.
Surgeon - Enter the name of the person doing the procedure.
Complications - Document if there are any complications experienced during the procedure.
Notes - write any notes that are worth taking during the procedure.
Dispensed Items Section
You will see this tab after adding a surgery procedure.
Click the plus (+) button to dispense items. These are the items that are non reusable items used during the surgery, for example bandages, syringes, needles, infusion sets, cotton balls, etc.
Search for the item and enter the item type. Finally click dispense.
Anesthesia Section
Click the pencil icon to add anesthesia.
Anesthesia Type - Enter the type of the anesthesia you will give the patient.
Anesthesia Technique - Enter the anesthesia technique used. This field will be activated once the anesthesia type has been entered.
Administered By - Enter the name of the person who administered the anesthesia.
Administered On - Enter the date and time when the anesthesia got administered. Click 'Set Now' if it's happening at that particular time.
Save the details.
Timeout Section
This section enables you to check to see if you are still working on the correct patient.
Verified 2x Patient Identifiers -check if it's the actual patient
Site Verified - confirm site to be operated
Procedure Verified - confirm which procedure to be done
Consent Reviewed - confirm if patient had signed consent
Witness Verified By - confirm if there is a witness
Surgeon Verified By - confirm the surgeon
Completed On - Time surgery was completion
POST OP TAB
Click the pencil icon to start editing post op notes. These notes are crucial for ensuring continuity of care and documenting the patient’s recovery progress
Click 'Set Time' button to set the time post op checklist was documented.
FOLLOW-UP TAB
An adverse events is any unintended injury or complication that occurs during or after a surgical procedure, which can result in harm to the patient.
Click '+ Adverse Event' button to add an an event.
Status - select if the condition was known prior to surgery
Adverse Event Code - select the adverse event code
Description - give a description of the adverse event
Started On - enter the date the adverse event started
Ended On - enter the date the adverse event ended
Save after entering details.
VITALS TAB
Click '+ Vitals' Add vitals taken during surgery.
MEDICATION TAB
Click '+ Order' to add medication orders to be administered during the surgery.
Click here to see how to add medication orders (Create Med order article)
QUICK ADD MED TAB
This will help you to quickly prescribe medication that is already configured in the system.
Click '+ Medication' in order to add the medication.
Select the mediation you want to prescribe.
Specify the quantity and save.
Click 'Add Prescription'.
ADMINISTERED MEDICATION TAB
Here you see all medication that has been administered to the patient during surgery and the time it was administered.
TIME & MOTION TAB
This shows you the time stamps of all activities during the surgery.