Diagnoses

As standard, the system will not display the diagnosis catalog associated with the diagnosis code in the diagnosis table. This is always the basic catalog for the case type which is stored in customizing for IS-H.

If you do not wish to use the basic catalog for specific organizational units, you can enter a diagnosis catalog in addition to the diagnosis code. A prerequisite for this is that the parameters N2OPDKI and N2OPDKIA must be maintained in the OU-related settings. You maintain these parameters under  Clinical System Basic Clinical Data Service Management Organizational Unit OU-Related Settings Maintain .

The parameter N2OPKDI defines which catalog should be used by default for the respective organizational unit on the entry screen of the SurgDocu. If this parameter is not maintained, the system will use the basic catalog stored in customizing for IS-H as the default but will not display this on the initial screen.

The parameter N2OPKDIA controls whether the preset diagnosis catalog should only be displayed on the entry screen, whether it is modifiable and whether it should appear as an input field. If the parameter N2OPDKI is not maintained, N2OPDKIA is without effect.

Entries in N2OPDKIA have the following effect:

Both OU-related parameters are interpreted hierarchically (see note for N2OPHCAN in text above).

You can enter diagnoses either with a diagnosis code or as a free text. Here you can indicate one or more diagnoses as the principal diagnoses for the surgery. When you then check and release these, the system will display a warning in such cases.

Transferring the Diagnosis from the Surgery Request

If you have entered a diagnosis in the surgery request, the system will offer you this diagnosis to be transferred as the principle diagnosis when you call the SurgDocu, providing no principle diagnosis was entered.

Entry of Diagnoses Using the Diagnosis Input Help Function ()DiagCatalog

In addition to selecting a diagnosis using the input help (F4), you can simultaneously transfer multiple diagnoses from the diagnosis catalog. To do this, choose DiagCatalog.

Entry of Diagnoses Using an External Coding System

If you execute diagnosis coding using an external coding system, you can use a multiple selection function to transfer multiple diagnoses.

The coding system must allow multiple selection and a BAdI must be defined as a customer enhancement in Customizing for diagnosis coding. Prerequisite: In Customizing under  Industry-Specific Component for Hospitals Medical/Nursing Documentation Define Input Help for Diagnosis Documentation you must have set the External Diagnosis Coding indicator and the BAdI for coding diagnoses must be active.

The multiple selection requires the cursor to be positioned on a diagnosis line that does not contain either a diagnosis code or user-defined diagnosis text.

You should note that for multiple selection the cursor must be positioned in a diagnosis row which contains neither a diagnosis code nor a diagnosis free text. Otherwise single selection is offered for coding the existing diagnoses.

Combined Coding Using an External Coding System

If the external coding system allows the combined evaluation and documenting of diagnoses and procedures, you can transfer diagnoses and procedures to the coding system for evaluation in one operation.

Prerequisite: The corresponding BAdI is configured and active in Customizing.

Multiple Transfer of Case-Related Diagnoses

Using Case Diagn you will receive a list of entered diagnoses. The cursor must be positioned on an empty diagnosis row. You can select and transfer one or more diagnoses.

Enhancement of the Diagnosis Entries with the Addition of the DRG Data

The system displays the DRG data in the diagnosis table if you have entered a DRG diagnosis catalog when customizing the parameters for the diagnosis documentation.

Link Diagnoses

Double-clicking a linked diagnosis undoes this link.

Procedures

You must always enter procedures with a procedure code. You can enter multiple principal procedures for one surgery. When you then check and release these, the system will display a warning in such cases.

If you enter a procedure without a localization which has the Localization Required indicator in the service master, the system will report an error.

If you use an enhanced surgery system catalog, you can use the official and unofficial procedure codes parallel to one another. Unofficial codes have the charge type 80. The official code assigned is in the Official OPS column.

You can assign requestable procedures to procedures for presetting, for the surgical documentation. See Presetting Procedures.

You can enter procedures in the SurgDocu, for example, by:

Entry of Procedures Using a Hit List

Prerequisites:

Procedure:

Entry of Procedures Using an External Coding System

If you use an external coding system to code the procedures you can use the multiple selection function to transfer multiple procedures. The coding system must allow multiple selection and a BAdI for procedure coding must be configured and activated in customizing for i.s.h.med.

You should note that for multiple selection the cursor must be positioned on a procedure row which contains no procedure key. Otherwise single selection is offered for coding the existing procedure.

Combined Coding Using an External Coding System

If the external coding system allows the combined evaluation and documenting of diagnoses and procedures, you can transfer diagnoses and procedures to the coding system for evaluation in one operation.

Prerequisite: The corresponding BAdI is configured and active in Customizing.

Enhancement of the Procedure Entries with the Addition of the DRG Data

The DRG data will be displayed in the procedure table if the surgery catalog (system parameter OP_TARIF) and the DRG surgery catalog (system parameter DRGTARIF) match in Customizing.

Support of Enhanced OPS 301

The charge type for unofficial procedures contains the value 80 in the procedure table. In Official OPS, the procedure code can be found at official procedures.

Text Transfer with Diagnoses and Procedures

The following rules apply for the display and transfer of text:

Long Text Display for Procedures and Requested Services

By double-clicking a service or a surgery code of the procedure table, you can display the service text from the corresponding catalog in its complete length.

Status Management for the Basic Medical Documentation

The surgical documentation supports the case status of basic medical documentation and the department status of basic medical documentation. The Change Diagnosis and Change Procedure processes are assigned to the Basic Medical Documentation status profile as status-related. If the status prevents you from changing the diagnoses or procedures, the corresponding diagnosis or procedure table is set to Display in the SurgDocu. You will see a corresponding message when you call the SurgDocu or change the case status. You will also receive a message if a process can only be provided with a warning.

For more information, see Status Management of Basic Medical Documentation.

Indicator for DRG Relevance

The indicator DRG relevance will be set if the procedure or the diagnosis was used for the DRG determination. An external coding system or grouping system will usually set this.

For general information about DRG processing, see Diagnosis Related Groups.

Team Documentation

Here you enter the surgical team involved in the surgery and the tasks of the team members.

When the surgery has been scheduled, the scheduled surgical team will be displayed. You can enter changes to the team and further tasks with the relevant employees. Input help is available for the Abbreviation and Task fields, the system will use the surgery date for the date.

Here you can maintain the personnel commitment time. If you leave this field blank, the system will use surgery time data to preset these fields before the SurgDocu is released. You must have assigned tasks to times for this to occur (see Surgery Times).

Using  Goto Team Entry you can access an alternative function for team entry.

Including the External Employee in the Team Documentation

In the team table, you can also enter external employees who are not stored in table NGPA as hospital employees.

Similar to the team entry window of the surgery monitor, you can enter external employees by choosing (-). The last name is mandatory here.

If you also enter the key of an internal employee for this task, the system will delete the data of the external employee. If you enter data for an external employee, the system will delete the key of an internal employee. For forensic reasons, you can also assign surgical procedures to external employees.

Assignment of Diagnoses to Procedures

You can assign any procedure to any diagnosis. For this assignment, you select in each case a procedure and a diagnosis and then choose (-) or  Edit Assign . You repeat this step if you wish to create several assignments. The system will display the assigned diagnoses or procedures in each diagnosis row or procedure row.

To delete assignments, select the relevant procedure and diagnosis and then choose (-) or choose  Edit Delete Assignment . You repeat this step if you wish to delete several assignments.

Assignment of OR Team Members to Procedures

You can assign any procedure to any member of the OR team. This assignment is a requirement for a qualified specialist certificate with the appropriate assignment. For forensic reasons, you can also assign procedures to external employees. For this assignment, you select in each case a procedure and a team member and then choose (-) or choose  Edit Assign . The system will display the assigned procedures for each team member in the team table.

To delete assignments, select the respective team member and the procedure and then choose (-) or  Edit Delete Assignment . You repeat this step if you wish to delete several assignments.

Adding Data to a Released Surgical Document

You can find more information about subsequently adding data in the section Releasing the Surgical Documentation.

Surgical Documentation Checks

When the surgical documentation is saved and checked, the check routines from IS-H for diagnoses and procedures are also used.

Besides the plausibility checks for entered values that are run directly after data entry when you choose Enter there are further checks that are generally only run when documentation is released or saved. Examples are the checks on missing surgery principle diagnosis and missing surgery principle procedure.

You can use the OU-related parameter N2OPCHECK to specify when these checks are to be performed:

The surgical documentation also takes into account the billing status of the case. With partially or final billed cases, the system displays corresponding messages when the surgical documentation is called. For procedures and diagnoses you can define in Customizing, using message control (NICP, N3 298, and NDIA, N6, 496), whether the corresponding table should be modifiable. If the message type is set to E, the corresponding table can no longer be changed. For more information about this, see Configurable Messages.

Customer-Specific Surgical Documentation Checks

Using the BAdI Consistency Check of Medical Documentation you can make your own checks in medical documentation. In Customizing you will find the BAdI under  Industry-Specific Component for Hospitals Medical/Nursing Documentation Business Add-Ins for Medical/Nursing Documentation . When the BAdI is active, the checks are run when your choose Rules or save.

For more information, see can Medical Documentation Checks.

Business Add-Ins for SurgDocu

You can find further notes on customer enhancements under Business Add-Ins.