Document Patient History for Pre-Operative Visits

You can document patient history such as surgery information, medications, allergies, and medical and surgical histories for pre-operative visits.

1. On the NB Preop v5 template, in the History panel, click the Get button.
   

   The surgery window opens displaying all surgery encounters with planned procedures for the patient.
2. Select an encounter from the surgery window, and click OK.
   The following details from the selected encounter are automatically filled in the corresponding fields. The options in the Pre-Surgical Checklist section are automatically updated from the Surgery Sched template on the selected encounter.

   • Clearance
   • Boarded procedures
   • Pre-Op and post-op medications
   • Medication instructions
   • Anesthesia provided
   • Labs and tests
3. To add additional medications and instructions, click the desired fields, and then select the option to be added from the list.
4. To generate a revised medication instruction, click the Create Document icon.
5. In the Checklist section, do the following:
   1. Click the blank field, select the appropriate check from the checks window, and then click OK.
   2. Indicate the applicability of the selected check.
   Note: You can enter additional values in the subsequent fields of each section.
6. In the Nasal Swab and Urine sections, select the appropriate options to indicate the corresponding test results.
   Note: If you select Positive for Nasal Swab, you can select the appropriate results from the list that opens.
7. In the Labs section, enter the test results in the corresponding fields.
8. Make the desired changes in the following sections.
   • Orthopedic Surgical History
   • Medical History
   • Surgical History
   • Medications
   • Allergy

   Note: These sections are automatically filled with the data documented on the Intake template. You can add, edit, and remove the data as needed.
9. Enter any additional history information in the Additional History field.