You can use the Post Op template to record the post-operative findings, including the patient's pre-operative status, history of present illness, and physical exam findings.
- On the Intake template, select the visit type as Post Op Visit.
The Post-Op template opens.
- In the Reason for Visit panel, select Surgery Follow Up from the HPI list.
If you do not see the surgery follow up option in the list, use Search, and select Surgery Follow Up from the search results.
Note: To enter the free text HPI portion of the visit, you can use the Generic HPI template.
The
Surgery Follow-up - HPI template opens.
- Select the post-operative status of the patient.
- To enter a saved default set, click Quick Load and Save.
- In the Interval History section, do the following:
- Indicate if the patient has pain.
If you select Yes, enter the location, level, and frequency of the pain.
- Indicate if the patient is using any pain medication.
If you select Yes, indicate the response options and how often the medication is taken.
- Indicate if there is any wound complication.
If you select Yes, select the complication level from the list.
- Indicate if there is any indwelling device.
If you select Yes, select the type and status of the device.
- Select the appropriate activity level, and enter the details.
- In the Associated Symptoms/Pertinent Negatives section, select the appropriate check box to indicate if there are no associated symptoms, pertinent negatives, or other issues.
- Select the appropriate negative or positive option next to the symptoms.
- Enter any other associated symptom and pertinent negative.
- Enter any additional information in Comments.
- To select the appropriate options for patient report, click ADLs and Functional Limitations.
- Click Save & Close.
