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Function documentationPreoperative Documentation

 

In this section, you can access information for preoperative documentation.

Definition of Orders
  • The orders represent a function that allows the performance of a procedure in relation to a patient in the system that you can preregister.

  • You can order any service in the in-house service catalog.

  • At the time at which the order is entered, it is not necessary to determine when the procedure is to be carried out or by whom it will be carried out.

  • The system saves an ordered procedure as a service with the ordered status.

  • You can request an ordered service in an i.s.h.med service management sense and then plan, perform, release and cancel it.

    Note Note

    You should note that the system does not currently support the creation of clinical orders from ordered services. If you use clinical orders, you must create a clinical order and enter the ordered service.

    End of the note.
Procedure Proposal

Procedure Proposal as an Input Help Function

During preparation for a surgery, you can order procedures which will generally be performed by different service facilities and the preparation care unit or outpatient clinic.

You can use the procedure proposal to provide a selection of procedures relating to a planned treatment (a surgery in the case of the surgery system) in the system. The procedures described by this proposal are services that different service facilities can perform and can therefore also be contained within various service ranges.

For each surgery, depending on the phase, the system offers a phase-related preoperative, intraoperative and a postoperative procedure proposal, which it will use each time you order a procedure.

As is the case with service grouping, you can nest the phase-related procedure proposals down any number of levels. For more information about setting up orders and the procedures catalg, see Setting Up Orders.

Using the Procedure Proposal

The procedure proposal is used in the surgery monitor and in the OR documentation.

  • In the surgery monitor, you must highlight the desired phase and then choose the Order pushbutton.

  • In OR documentation (e.g. in the preoperative anamnesis log), choose the Order pushbutton. Since documents are related to specific phases, the phase used for each document is already implemented.

A dialog box appears where you can enter the services for the orders. Save the entries.

Since documents are related to specific phases, the phase used for each document is already implemented.

The system will display the ordered services in the surgery monitor in phase-related form.

When you define this, you can add long text relating to the suggestion and the service (e.g. a note or a basic medication table) to the procedure proposal. The system displays this text instead of the service name in the surgery monitor. If you click the hotspot on the service, you will branch to the editing function, where you can edit the long text for individual patients.

Note Note

You can use the preselection function for defining procedure proposals. You can find information on defining a preoperative preselection under Service Range.

End of the note.
Orders on Free Text Basis

You cannot enter every procedure using the services listed in the hospital service catalog. For this reason, i.s.h.med provides the option of entering user-defined text orders. You can use this tool to formulate a user-defined text order as an alternative to the services selected in the procedure proposal. After you save it, the system will also display this text as an ordered service in the surgery monitor. For more information, see Configure Orders in Free Text Basis.

Printing Orders

You can also print orders. The system provides a report for this which can be printed for each phase from the surgery monitor. To print orders select the phase in the surgery monitor and then choose   Goto  Orders  .

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