Release Surgical Documentation
You can release the surgical documentation (SurgDocu), if you have entered all procedures, diagnoses and team members for the surgery.
Releasing these will confirm all requested surgical services and expand the service groups. If you customize it appropriately, the system will additionally generate IS-H hospital catalog services from the procedures in the background. If possible, the system will display proposals for transferring missing time entries for the surgery team from the surgery time entry.
You cannot and should not modify a released SurgDocu. It will appear in the display mode.
You can no longer use i.s.h.med to synchronize procedures or diagnoses that you additionally entered with the IS-H function Change Surgery
(NP38
) after releasing. For this reason, these will not appear in the released SurgDocu for the surgery. You can find more detailed information in the section Synchronizing Surgical Data with IS-H.
Releasing Assigned Documents
When the surgical documentation is released, assigned documents can be automatically released. Prerequisite: In the Document Profile of the performing OU I
(Internal Coding)
contains C for Surgical Documentation
.
Subsequently Entering and Correcting Exceptional Cases
In order to be able to change surgical data in exceptional cases, despite released SurgDocu, you can still add missing data, correct existing data or synchronize data with IS-H for a period of up to seven days, starting from the release date.
Subsequent Entry Procedure
When you call the SurgDocu, a dialog box will show you which employee released the SurgDocu and when the employee carried this out. At the same time, the system will ask if you want to make subsequent entry.
If you delete procedures in Subsequent Entry, for which the system generated IS-H hospital catalog services in the background when you were releasing them, the system will require you to also delete the generated services in IS-H. You can cancel the deletion of the procedure here.
After this period expires, if you call the SurgDocu the system will display in the message line which employee released or added to the SurgDocu and when they did this.
Authorized employees, for example, coding directors and chief physicians can use the additional authorization to correct the SurgDocu during the 7-day period mentioned.
A special authorization is required for subsequently entering or changing released surgical documentation:
Authorization object N_2MEDOK
with the following attributes:
Activity
= “C8“
ID of the document category
= “$CHIRDOKU”
Institution
Documenting Org. Unit
Note
You should only assign this authorization in exceptional cases to ensure that the released surgical documentation is not usually subsequently changed.