Document Findings in the Post-op Rapid Note Template
To access the Post-op Rapid Note template, you need to select Orthopedics as the specialty and Post OP Visit as the visit type.
In the SOAP template, click the Rapid Note link.
The Post-op Rapid Note template opens.
In the Surgical History panel, do the following:
Click the Facility field and select a facility.
In the Surgery Type field, click the Inpatient, Outpatient or Observation option to indicate the type of surgery.
Click the Surgeon field and select the physician name.
Click the Assistant field and select the assistant who assisted the surgeon during surgery.
Click the Assessment field to access the picklist.
Select an assessment and click OK.
Note: If the patient's diagnosis/assessment is not added earlier, the diagnosis search window is displayed when you click the Assessment field to search for and select a diagnosis.
Click the Procedure field.
The Select Procedure window opens.
Search a procedure and select a procedure from the search result, and then click OK.
Click the Side field and select an option from the Side picklist.
Click the Region field or blue down arrow beside the field and select a location from the Region picklist.
Click the top blank row in the Region picklist to type a location in the Region field.
Click the Proc Date field and select the date from the calendar.
Click Add.
The selected procedure is displayed in the data grid.
Highlight the procedure in the data grid and click the Confirm button to complete the procedure.
Note: To update or modify an assessment available in the data grid, highlight a row in the data grid and make necessary changes in the fields, and then click the Confirm button.
In the HPI panel, do the following:
Highlight the required procedure in the grid in the Surgical History panel and expand the HPI panel.
Click the following fields and select an appropriate option from the corresponding picklists:
Activity Level
Work Status
Pain level
Frequency of pain
Healing status
Other
Click the improving, no change, or worsening option for Post-op status.
Click the no or yes option for Pain meds.
Click the full, non-weight bearing, partial, or toe touch option for WB status.
Click the No or Yes option for the following fields:
Wound healing
Calf tenderness
Fever/chills
Rehabilitation
Nausea/vomiting
Swelling
Home exercises
Using assistive devices
In the Physical Exam panel, do the following:
Select any of the following checkboxes to record the post-op PE findings:
Click the fields and select options from the corresponding picklist.
In the Assessment/Plan panel, do the following:
Select a diagnosis from the Today's Assessment data grid.
The Add Common Assessment and Add Injury/Fracture Assessment links are used to select specialty-specific assessments.
Select any of the checkboxes to indicate the plan details for post-op treatments and precautions.
To add other plan details, click the Other field and select a plan from the Plan picklist.
If you need to schedule a follow-up visit, select the Schedule follow-up visit checkbox and then select the As needed checkbox so that patients can visit according to their convenience.
Click the Time limit field and select a time limit from the list.
Click the Time frame field and select a time from the picklist.
Select any of the checkboxes to indicate the reason for next visit.
Click the Other fields to indicate another reason for visit from the Reason for Next Visit picklist.
Click Save & Add New.
The Select Task Recipients window opens.
Select the user(s) to whom the task should be assigned.
Click the Add User(s) button.
Click OK to return to the Post-op Rapid Note template.
All the fields in the Post-op Rapid Note template are cleared.
Enter any other post-op details in the Post-op Rapid Note template.
Click Save & Close.
The data is displayed in the data grid in the Reason for Visit panel.
Document Findings in the Post-op Rapid Note Template
