Surgical History & Procedure Section

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Use the Surgical History & Procedure section to view and record the patient's surgical and procedure history.

 

Use the Surgical History & Procedure section to view and record the patient's surgical and procedure history.

 

On the History tab of the patient chart, navigate to Surgical & Procedure History. Or, at the top of the History section, click the Go to menu and select Surgical & Procedure History..

 

 

 

  1. On the History tab of the patient chart, navigate to Surgical & Procedure History. Or, at the top of the History section, click the Go to menu and select Surgical & Procedure History..
  2. Click the plus icon to add an item.
  3. Type three or more characters to start searching for a procedure, and then select the procedure.
    CPT-backed procedures and SNOMED-backed procedures are listed first, followed by procedures that you configured on the Surgical History Questions page.
  4. Procedure Date — Enter the date of the procedure.
  5. Laterality — Select the laterality: Left, Right, or Bilateral.
    This field appears only when you select a SNOMED-backed procedure that requires laterality.
  6. To add a note about the procedure, click Note, and then enter the note.
  7. If you need to add a series of historical procedures, click Add another date. Record the date for the second procedure or surgery and add a note, if appropriate. Repeat this step until you record all past instances of this procedure or surgery.
    Tip: If you accidentally click Add another date, you can click outside the form to close the form.
  8. Click Add.

 

  1. On the History tab of the patient chart, navigate to Surgical & Procedure History. Or, at the top of the History section, click the Go to menu and select Surgical & Procedure History.
  2. Click an item in the list to expand and view the details.
  3. Edit the fields as needed.
  4. Click the X icon to delete the item.
  5. Click the expanded view to close the item details.

 

 

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