Document Pre-Operative Visit Details

You can document the details and recommend any test for a patient before surgery.

1. In the left Navigation bar, select Pre Op Visit.
   The Preop visit template opens displaying the assessment, orders, medication, and allergies details documented on the Intake and SOAP templates.

   

2. To enter the surgery details, select Schedule Procedures.
   The Surgery Orders grid displays the details of the scheduled surgery.
3. In the Consents section, do the following:
   1. Select the appropriate option after explaining the procedure details to the patient.
   2. Select Risk detail, and select the relevant pre-operative risks.
   3. Select the appropriate option for Agrees to blood/blood products?
      If you select no, select the Signed blood/blood product refusal form check box.
   4. To open the Preop Checklist template, select the Preop Checklist link.
      • Select the appropriate option for Risk Factors, Bleeding Risk, Medication Review, and Anesthesia Risk.
      • Provide details if the patient is sensitive to anesthesia and has a family history of bleeding risk.
   5. To enter any additional information, select Comments.
4. In the Preop Studies section, do the following:
   1. To select any lab test required for the diagnosis and place the order, select Labs.
   2. To place any diagnostic studies order, select Diagnostics.
   3. To document information on the referral, which includes insurance name, policy number, provider details, and clinical details, select Referrals.
   4. Indicate if no lab tests are needed.
   5. To add diagnostic history details, select Add Historical Orders.
   6. Select the appropriate options for the order that you want to appear in the All Orders grid.
5. To generate the preop_visit document in runtime, select Preview Document.
6. To save the details, select Update.