[604] | 1 | English French Notes Complete/Exclude
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| 2 | Dosage entered incorrectly.
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| 3 | Dosage must be 1 to 15 characters in length, i.e. 15 mg.
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| 4 | ENTER DOSE:
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| 5 | SHORT SCREEN
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| 6 | POST OPERATION
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| 7 | SURGICAL STAFF
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| 8 | REVIEW REQUEST
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| 9 | An operative procedure must be selected to use this option.
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| 10 | ... Modifier deleted
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| 11 | CPT Modifier '
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| 12 | ' is not acceptable with this CPT code.
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| 13 | Answer with PRIN. PROCEDURE CPT MODIFIER
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| 14 | You may enter a new PRIN. PROCEDURE CPT MODIFIER, if you wish.
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| 15 | Answer with OTHER PROCEDURE CPT MODIFIER
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| 16 | You may enter a new OTHER PROCEDURE CPT MODIFIER, if you wish.
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| 17 | The Morbidity and Mortality Reports include the Perioperative Occurrences
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| 18 | Report and the Mortality Report. Each report will provide information
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| 19 | from cases completed within the date range selected.
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| 20 | Do you want to generate both reports
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| 21 | Enter '1' to print the Perioperative Occurrences Report, or '2' to print the Mortality Report
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| 22 | 1. Perioperative Occurrences Report
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| 23 | 2. Mortality Report
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| 24 | MORTALITY REPORT
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| 25 | No mortalities for the selected date range.
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| 26 | AUTOPSY (Y/N)
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| 27 | Annual Report of Non-O.R. Procedures
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| 28 | Print the report on which Device:
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| 29 | ANNUAL REPORT OF NON-O.R. PROCEDURES
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| 30 | TOTAL NON-O.R. PROCEDURES FOR
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| 31 | TOTAL NON-O.R. PROCEDURES:
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| 32 | SUMMARY OF ALL SPECIALTIES
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| 33 | CPT - PROCEDURE
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| 34 | Reason an Assessment was not Created
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| 35 | According to your records, an assessment should be created for this surgical
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| 36 | Do you want to update this information and not create a surgery risk
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| 37 | assessment for this case ? NO//
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| 38 | If this case will not be used for the risk assessment study, Enter 'YES' to
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| 39 | change the status. You will then be prompted for the reason that no assessment
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| 40 | was done. Enter 'NO' to leave this case unchanged.
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| 41 | If you delete the reason why no assessment was created for this case, the
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| 42 | computer will automatically update your records to make this a non-assessed
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| 43 | Are you sure that you want to delete the reason ? NO//
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| 44 | By entering an '@', you have told the computer that you want to remove the
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| 45 | reason why no assessment was created for this case. If this reason should be
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| 46 | Updating to non-assessed status...
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| 47 | >>> The patient you have selected died on
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| 48 | Are you sure this is the correct patient ?
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| 49 | Entering a new surgical case for
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| 50 | Select the Date of Operation:
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| 51 | When entering a new surgery case, a date MUST be entered. If you do not
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| 52 | know the date of operation, enter this patient on the Waiting List.
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| 53 | Select Surgeon:
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| 54 | The person you selected does not have the appropriate keys necessary to be
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| 55 | entered as a surgeon. Please make another selection.
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| 56 | Select Surgical Specialty:
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| 57 | NEW SURGERY
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| 58 | Do you want to continue ? YES//
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| 59 | Enter RETURN if you want to re-enter a date and continue creating a new
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| 60 | case, or 'NO' to leave this option.
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| 61 | NURSE INTRAOPERATIVE REPORT
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| 62 | Operating Room:
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| 63 | Surgical Priority:
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| 64 | Patient in Hold:
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| 65 | Patient in OR:
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| 66 | Operation Begin:
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| 67 | Operation End:
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| 68 | Surgeon in OR:
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| 69 | Patient Out OR:
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| 70 | First Assistant:
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| 71 | Attending Surg:
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| 72 | Second Assistant:
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| 73 | Assistant Anesth:
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| 74 | Other Scrubbed Assistants:
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| 75 | NURSE'S SIG:
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| 76 | SF 509 PROGRESS NOTES
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| 77 | Press RETURN to continue with this report, or '^' to return to the
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| 78 | previous menu.
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| 79 | MEDICAL RECORD | NURSE INTRAOPERATIVE REPORT PAGE
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| 80 | OR Support Personnel:
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| 81 | Circulating
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| 82 | Other Persons in OR:
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| 83 | Preop Mood:
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| 84 | Preop Consc:
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| 85 | Preop Skin Integ:
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| 86 | Preop Converse:
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| 87 | Valid Consent/ID Band Confirmed By:
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| 88 | NO, SEE NURSING CARE COMMENTS
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| 89 | Time Out Verification Completed:
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| 90 | Preoperative Imaging Confirmed:
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| 91 | Skin Prep By:
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| 92 | Skin Prep Agent:
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| 93 | Skin Prep By (2):
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| 94 | 2nd Skin Prep Agent:
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| 95 | Preop Shave By:
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| 96 | Surgery Position(s):
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| 97 | Placed:
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| 98 | Restraints and Position Aids:
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| 99 | Electrocautery Unit:
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| 100 | ESU Coagulation Range:
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| 101 | ESU Cutting Range:
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| 102 | Electroground Position(s):
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| 103 | Major
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| 104 | Minor
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| 105 | Operations Performed:
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| 106 | Other:
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| 107 | Material Sent to Laboratory for Analysis:
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| 108 | Specimens:
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| 109 | Cultures:
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| 110 | Anesthesia Technique(s):
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| 111 | Tubes and Drains:
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| 112 | Tourniquet:
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| 113 | Time Applied:
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| 114 | Time Released:
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| 115 | Site Applied:
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| 116 | Pressure Applied (in TORR):
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| 117 | Thermal Unit:
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| 118 | Prosthesis Installed:
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| 119 | Medications:
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| 120 | Irrigation Solution(s):
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| 121 | Temperature:
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| 122 | Time On: N/A
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| 123 | Time Off: N/A
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| 124 | Time On:
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| 125 | Time Off:
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| 126 | Item:
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| 127 | Lot/Serial Number:
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| 128 | Sterile Resp:
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| 129 | Size:
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| 130 | Time Administered:
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| 131 | Administered By:
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| 132 | Time Used:
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| 133 | Blood Replacement Fluids:
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| 134 | Sponge Count:
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| 135 | Sharps Count:
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| 136 | Instrument Count:
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| 137 | Counter:
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| 138 | Counts Verified By:
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| 139 | Dressing:
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| 140 | Packing:
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| 141 | Blood Loss:
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| 142 | Postoperative Mood:
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| 143 | Postoperative Consciousness:
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| 144 | Postoperative Skin Integrity:
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| 145 | Postoperative Skin Color:
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| 146 | Type of Laser:
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| 147 | Sequential Compression Device:
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| 148 | Wound Classification:
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| 149 | Discharged Via:
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| 150 | Nursing Care Comments:
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| 151 | NO COMMENTS ENTERED
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| 152 | Source Identification:
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| 153 | VA Identification:
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| 154 | Transmit Surgery Risk Assessments
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| 155 | NON-O.R. PROCEDURE REPORT
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| 156 | MEDICAL RECORD | NON-O.R. PROCEDURE REPORT PAGE
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| 157 | Case #:
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| 158 | PROVIDER'S SIG:
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| 159 | Non-O.R. Procedures for
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| 160 | (DIED ON
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| 161 | Enter the number corresponding to the procedure for which you want to print
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| 162 | NON-O.R. PROCEDURES FOR
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| 163 | Med. Specialty:
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| 164 | Principal Diagnosis:
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| 165 | ICD9 CODE:
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| 166 | Patient Status:
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| 167 | 3. ATTENDING NOT PRESENT,
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| 168 | Att Code:
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| 169 | BUT AVAILABLE
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| 170 | Attend Anesth:
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| 171 | Anesthesia Supervisor Code:
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| 172 | Anesthesia Technique:
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| 173 | Diagnostic/Therapeutic (Y/N):
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| 174 | Anes Begin:
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| 175 | Anes End:
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| 176 | Proc Begin:
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| 177 | Proc End:
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| 178 | Procedure(s) Performed:
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| 179 | Procedure Code Comments:
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| 180 | Indications for Procedure:
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| 181 | Specimens:
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| 182 | Provider's Dictation:
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| 183 | Occurrences:
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| 184 | NEW PROCEDURE
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| 185 | ' or 'NEW' to create a new procedure
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| 186 | Do you want to edit or delete this procedure ?
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| 187 | Enter '1' to edit information related to this procedure, or '2' to delete
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| 188 | this procedure from your records.
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| 189 | NON-O.R. PROCEDURE
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| 190 | Select procedure or press RETURN to continue listing procedures:
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| 191 | Enter the number corresponding to the desired procedures
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| 192 | create a new procedure,
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| 193 | or press RETURN to continue listing procedures.
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| 194 | If the desired procedure does not appear, press RETURN to continue
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| 195 | listing additional procedures
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| 196 | , or enter 'NEW' to create a new procedure
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| 197 | Press RETURN to continue.
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| 198 | >>> The procedure you have selected has a future date.
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| 199 | Are you sure you have selected the correct procedure ?
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| 200 | Entering a new non-O.R. procedure for
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| 201 | Enter the Procedure:
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| 202 | Select the Date of the Procedure:
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| 203 | The Date of the Procedure MUST be entered.
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| 204 | Medical Specialty
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| 205 | Are you sure that you want to remove this procedure from your
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| 206 | No action taken...
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| 207 | Enter RETURN or 'NO' if this procedure should remain on file. Enter 'YES'
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| 208 | to delete this procedure.
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| 209 | Deleting procedure...
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| 210 | Report of Non-OR Procedures
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| 211 | How do you want the report sorted ?
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| 212 | 1. By Specialty
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| 213 | 2. By Provider
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| 214 | 3. By Location
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| 215 | Enter '1' to sort this report by specialty, '2' to list
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| 216 | procedures sorted by provider, or '3' to list procedures sorted by location.
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| 217 | Do you want to print the report for all Providers ? YES//
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| 218 | Enter RETURN to print the report for all providers, or 'NO'
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| 219 | to select a specific provider.
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| 220 | Print the Report for which Provider ?
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| 221 | REPORT OF NON-O.R. PROCEDURES
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| 222 | SRSUR*
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| 223 | Do you want to print the report for all Specialties ? YES//
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| 224 | Enter RETURN to print the report for all Specialties, or 'NO'
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| 225 | to select a specific specialty.
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| 226 | Print the Report for which Specialty ?
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| 227 | SRSPEC*
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| 228 | No procedures for the selected date range.
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| 229 | LOCATION NOT ENTERED
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| 230 | PATIENT (ID#)
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| 231 | LOCATION (IN/OUT-PAT STATUS)
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| 232 | FINISH TIME
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| 233 | There were no procedures entered for the date range selected.
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| 234 | PROVIDER NOT ENTERED
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| 235 | Do you want to print the report for all Locations ? YES//
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| 236 | Enter RETURN to print the report for all locations, or 'NO'
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| 237 | to select a specific location.
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| 238 | Print the Report for which location ?
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| 239 | SRLOC*
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| 240 | SPECIALTY (IN/OUT-PAT STATUS)
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| 241 | TALKS CONSTANTLY
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| 242 | INITIATES CONVERSATION
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| 243 | RESPONDS TO QUESTIONS
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| 244 | DOESN'T ANSWER QUESTIONS
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| 245 | (FULLY TRAINED)
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| 246 | Cultures:
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| 247 | Postoperative Consciousness:
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| 248 | MEDICAL RECORD | NURSE INTRAOPERATIVE REPORT PAGE
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| 249 | Nurse's Signature:
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| 250 | SF 509 Progress Notes
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| 251 | Case Type:
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| 252 | Pat in Holding:
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| 253 | Pat in OR:
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| 254 | Operation Begin:
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| 255 | Pat Out OR:
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| 256 | First Assist:
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| 257 | Attend Surg::
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| 258 | OR Support Personnel:
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| 259 | Scrubbed
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| 260 | Valid Consent Confirmed By:
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| 261 | Preop Cons:
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| 262 | Preop Skin Color:
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| 263 | Skin Prepped By:
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| 264 | Skin Prep Agent:
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| 265 | Second Prep Agent:
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| 266 | (FULLY TRAINED)
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| 267 | Prosthesis Installed:
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| 268 | Irrigation Solution(s):
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| 269 | NOT CORRECT, SEE NURSING CARE COMMENTS
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| 270 | Sponge Count:
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| 271 | Counter::
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| 272 | Adm By:
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| 273 | VA ID:
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| 274 | Preop Shave By:
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| 275 | CLEAN/CONTAMINATED
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| 276 | Wound Clssification:
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| 277 | Restraints and Position Aids:
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| 278 | Electrocautery:
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| 279 | Major
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| 280 | Minor
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| 281 | Operation(s) Performed:
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| 282 | Other:
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| 283 | Material Sent to Laboratory for Analysis:
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| 284 | On:
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| 285 | Sponge, Sharps, and Instrument Count Verified As
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| 286 | First Verifier:
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| 287 | Second Verifier:
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| 288 | Packing:
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| 289 | Postop Mood:
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| 290 | Postop Cons:
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| 291 | Postop Skin Integrity:
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| 292 | Postop Skin Color:
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| 293 | Surgical Nurse Staffing Report
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| 294 | Enter RETURN to print the Surgical Nurse Staffing Report for all nurses, or
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| 295 | 'NO' to select a specific person.
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| 296 | Print the Nurse Staffing Report for which Nurse ?
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| 297 | SURGICAL NURSE STAFFING REPORT
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| 298 | SRSD*
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| 299 | SRED*
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| 300 | SRONUR*
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| 301 | Normal Daily Schedules for Operating Rooms
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| 302 | Enter the name of the operating room:
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| 303 | #################### #################### ####################
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| 304 | #################### #################### ####################
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| 305 | #################### #################### ####################
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| 306 | #################### #################### ####################
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| 307 | #################### #################### ####################
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