Surgery Sample Documents
Parameterized document categories (PMDs) are an important tool for user-specific documentation. You can assign these to the preoperative, intraoperative, or postoperative branch of the surgery monitor using the OU-related document profile (see Configure Document Profile).
i.s.h.med contains sample document categories which you can copy and adapt for your own PMDs. This selection of sample document categories does not represent complete documentation, but is only intended as an example.
Caution
In future releases sample document categories may be discontinued, changed by SAP, or enhanced by the addition of new document categories.
Current Sample Document Categories
The following surgery sample document categories are available:
| Surgery log (nursing) |
| Surgery report (physician) |
| Additional document (physician) |
| Sample covering letter |
Caution
You are not allowed to use the delivered sample documents directly or in modified form in a productive system. You should first create a copy before you use sample documents with or without changes in your system (see Formatting Surgery Documents).
Surgery Log (Surgery Nursing)
In this document, surgical nurses can document their procedures during an operation.
The surgery log is documented b the surgery nursing staff. You can enter information concerning, for example, the position, disinfection, tourniquets, drainages, materials, and devices.
The fields for these entries have been partially implemented as combo boxes, so that the system administrator can individually create or modify the list of possible entries for the input help function (see Maintenance of Proposal Values for Combo Boxes).
Especially for implants and dilutions/drugs, you can make multiple selections from a predefined list, if the system administrator has maintained values in this selection list. You maintain this data on the SAP Easy Access
screen by choosing 
Clinical System
Service Management
Clinical Service Master
Service /Material
.
In the comments field for the count control, you can enter reasons for differences that may occur.
You can select implants from a list and document their associated batch numbers. The system will automatically enter the implant name.
You can document changes for the planned team here.
Surgery report (physician)
The surgery report is designed for the physician who documents the surgery progress as free text.
In Indication
, Report
and Recommendations
you can enter long texts.
On the Diagnoses / Procedures / Team
tab page, data is displayed which is entered in the Surgical Documentation (programmed dialog application) or using the dialog applications for diagnosis or procedure entry.
Additional document (physician)
The additional surgery sample document is designed for a physician's post-treatment orders outside of the operating room.
In the Drugs
table you can enter presettings for post-treatment medication.
Sample covering letter
The sample covering letter is used when sending samples to the pathology department.
You can enter several preparations and diagnoses (also as long text). A larger text field is provided for the questions/problem.