Medical History: Surgery List

The following topics are discussed on this page. Use the links to jump to the desired subject:

Introduction to the Surgery List

The surgery list allows you to capture and maintain a list of all surgeries a patient has had over time. A chronological change log is also available, which records the original content, change reason, and an audit trail of the user ID and date/time stamp.

To access the surgery list page, use one of the following methods:

(Preferred method) From the Hospital dashboard, use the Select button to select the appropriate patient using the drop-down list. Then, click the Surgical button. The Medical History: Surgery page is displayed.

Click the Surgical button on the Hospital dashboard. The Patient Search box is displayed. Begin typing the patient information. See Selecting Patients for additional details on using this feature.

Once the patient is selected, the patient's basic episode information is displayed in the yellow bar at the top of the screen, including: patient name, DOB, and medical record number.

All surgeries display the surgery description, surgery date, verified date, and entered notes. In addition, the following function buttons are displayed to the right of each surgery on the list:

	Edit button: Click to edit a surgery. See To edit a surgery.
	Remove button: Click to remove a surgery from the surgery list. See To remove a surgery.
	View Change Log button: Click to view all details of surgery change. See To view the Change Log. To return to the Surgery List, click Back.

To sort the Surgery History

The surgery list can be sorted by surgery description or surgery date. The default view displays all surgeries by surgery date (in reverse chronological order). To change your view, use the drop-down list in the Sort field to select the desired view option. Once selected, the list is resorted accordingly.

To add a surgery

Click Add Surgery located at the top of the page. The Add Surgery box is displayed.
In the Surgery field, you can enter the surgery in free text or you can select a CPT code. To select an CPT code, begin typing part of the surgery description. A list of possible matches appears as you type. You can continue typing to narrow down the list. Highlight and select the desired surgery.
In the Surgery Date field, use the drop-down list to select Day, Month, or Year. In the blank date field to the right, click the calendar to select the date the patient had the surgery. The date is automatically formatted according to the selected day, month, or year.
The Age field displays the calculated age of the patient based on the DOB and the Surgery Date field. If you enter a value in the Age field, the Surgery Date is also automatically calculated/displayed when you click in the Surgery Date field.
In the Notes field, you can type a free-text message about the surgery.
Click Save and Add More to add the surgery and remain in the window to add additional surgeries.
Or, click Save and Close to save your work and return to the surgery list.

To verify the Surgery List (No Change)

The No Change option allows you to indicate that you have reviewed and verified that the surgery list is correct and hasn't changed since the last assessment/review.

Click No Change located at the upper right-hand corner of the window.
A message box is displayed with the message, Would you like to mark all surgeries as being reviewed and verified? Select Yes to indicate you have reviewed and verified the surgery list, and click Save; or select No or click Close if you do not want to perform the verification at this time. Once reviewed, the user name and date/time displayed in the Verified field is updated.

To edit a surgery

Click the Edit button next to the surgery you want to edit. The Edit Surgery box is displayed. Edit any of the fields as needed. See To add a surgery above for field descriptions.
In the Reason field, use the drop-down list to select a reason for the edit. To enter a reason that is not listed, select Other (See notes) from the list and type in the required free-text reason in the Other Reason field.
Click Save to save your changes and return to the surgery list, or click Close if you want to cancel your changes.

To remove a surgery

Click the Remove button next to the surgery you want to remove. The Remove Surgery box is displayed.
In the Reason field, use the drop-down list to select a reason for removing the surgery. To enter a reason that is not listed, select Other (See notes) from the drop-down list and type the required free-text reason in the Other Reason field.
Click Remove to continue. You are returned to the surgery list with the surgery now removed.

To view the change log

A change log is available to view all details of a change made to the surgery. The log records when a surgery is added, edited, or removed, and contains the login name of who made the change, a reason for the change, and both the original and new values of the surgery description, surgery date, and notes.

There are two ways to access the change log:

Click View Change Log at the top of the screen to view changes for all surgeries on the list.
Click the button next to a particular surgery to view changes for only that surgery.

On the Surgery Change Log page, surgeries are displayed according to the date/time they were changed, with the most recent change first. You can alter your view to display only added, edited, or removed surgeries, as well as, sort the surgeries by description. To change your view, use the drop-down lists in the Filter and Sort fields to select your desired view options. Once selected, the list is resorted accordingly.

The default view allows you to view a quick list of problem changes showing only the date/time, user, problem, and action (added, edited, or removed). Click the show details icon next to a particular problem to display additional details for that item. Click Show All Details to display additional details for all the item changes.

Click Back to leave the change log and return to the surgery list.

To generate the CCD (Continuity of Care Document)

The CCD is a clinical summary document generated from the patient's clinical information, including insurance providers, advance directive information, problem list, and medication information. This document opens in a new browser tab, where it can be e-mailed, saved, and/or printed to the patient and/or another healthcare provider. To generate the CCD, click the Generate CCD button.

To print the list

To print a copy of the list, click the Print button.