English French Notes Complete/Exclude Dosage entered incorrectly. Dosage must be 1 to 15 characters in length, i.e. 15 mg. ENTER DOSE: SHORT SCREEN POST OPERATION SURGICAL STAFF REVIEW REQUEST An operative procedure must be selected to use this option. ... Modifier deleted CPT Modifier ' ' is not acceptable with this CPT code. Answer with PRIN. PROCEDURE CPT MODIFIER You may enter a new PRIN. PROCEDURE CPT MODIFIER, if you wish. Answer with OTHER PROCEDURE CPT MODIFIER You may enter a new OTHER PROCEDURE CPT MODIFIER, if you wish. The Morbidity and Mortality Reports include the Perioperative Occurrences Report and the Mortality Report. Each report will provide information from cases completed within the date range selected. Do you want to generate both reports Enter '1' to print the Perioperative Occurrences Report, or '2' to print the Mortality Report 1. Perioperative Occurrences Report 2. Mortality Report MORTALITY REPORT No mortalities for the selected date range. AUTOPSY (Y/N) Annual Report of Non-O.R. Procedures Print the report on which Device: ANNUAL REPORT OF NON-O.R. PROCEDURES TOTAL NON-O.R. PROCEDURES FOR TOTAL NON-O.R. PROCEDURES: SUMMARY OF ALL SPECIALTIES CPT - PROCEDURE Reason an Assessment was not Created According to your records, an assessment should be created for this surgical Do you want to update this information and not create a surgery risk assessment for this case ? NO// If this case will not be used for the risk assessment study, Enter 'YES' to change the status. You will then be prompted for the reason that no assessment was done. Enter 'NO' to leave this case unchanged. If you delete the reason why no assessment was created for this case, the computer will automatically update your records to make this a non-assessed Are you sure that you want to delete the reason ? NO// By entering an '@', you have told the computer that you want to remove the reason why no assessment was created for this case. If this reason should be Updating to non-assessed status... >>> The patient you have selected died on Are you sure this is the correct patient ? Entering a new surgical case for Select the Date of Operation: When entering a new surgery case, a date MUST be entered. If you do not know the date of operation, enter this patient on the Waiting List. Select Surgeon: The person you selected does not have the appropriate keys necessary to be entered as a surgeon. Please make another selection. Select Surgical Specialty: NEW SURGERY Do you want to continue ? YES// Enter RETURN if you want to re-enter a date and continue creating a new case, or 'NO' to leave this option. NURSE INTRAOPERATIVE REPORT Operating Room: Surgical Priority: Patient in Hold: Patient in OR: Operation Begin: Operation End: Surgeon in OR: Patient Out OR: First Assistant: Attending Surg: Second Assistant: Assistant Anesth: Other Scrubbed Assistants: NURSE'S SIG: SF 509 PROGRESS NOTES Press RETURN to continue with this report, or '^' to return to the previous menu. MEDICAL RECORD | NURSE INTRAOPERATIVE REPORT PAGE OR Support Personnel: Circulating Other Persons in OR: Preop Mood: Preop Consc: Preop Skin Integ: Preop Converse: Valid Consent/ID Band Confirmed By: NO, SEE NURSING CARE COMMENTS Time Out Verification Completed: Preoperative Imaging Confirmed: Skin Prep By: Skin Prep Agent: Skin Prep By (2): 2nd Skin Prep Agent: Preop Shave By: Surgery Position(s): Placed: Restraints and Position Aids: Electrocautery Unit: ESU Coagulation Range: ESU Cutting Range: Electroground Position(s): Major Minor Operations Performed: Other: Material Sent to Laboratory for Analysis: Specimens: Cultures: Anesthesia Technique(s): Tubes and Drains: Tourniquet: Time Applied: Time Released: Site Applied: Pressure Applied (in TORR): Thermal Unit: Prosthesis Installed: Medications: Irrigation Solution(s): Temperature: Time On: N/A Time Off: N/A Time On: Time Off: Item: Lot/Serial Number: Sterile Resp: Size: Time Administered: Administered By: Time Used: Blood Replacement Fluids: Sponge Count: Sharps Count: Instrument Count: Counter: Counts Verified By: Dressing: Packing: Blood Loss: Postoperative Mood: Postoperative Consciousness: Postoperative Skin Integrity: Postoperative Skin Color: Type of Laser: Sequential Compression Device: Wound Classification: Discharged Via: Nursing Care Comments: NO COMMENTS ENTERED Source Identification: VA Identification: Transmit Surgery Risk Assessments NON-O.R. PROCEDURE REPORT MEDICAL RECORD | NON-O.R. PROCEDURE REPORT PAGE Case #: PROVIDER'S SIG: Non-O.R. Procedures for (DIED ON Enter the number corresponding to the procedure for which you want to print NON-O.R. PROCEDURES FOR Med. Specialty: Principal Diagnosis: ICD9 CODE: Patient Status: 3. ATTENDING NOT PRESENT, Att Code: BUT AVAILABLE Attend Anesth: Anesthesia Supervisor Code: Anesthesia Technique: Diagnostic/Therapeutic (Y/N): Anes Begin: Anes End: Proc Begin: Proc End: Procedure(s) Performed: Procedure Code Comments: Indications for Procedure: Specimens: Provider's Dictation: Occurrences: NEW PROCEDURE ' or 'NEW' to create a new procedure Do you want to edit or delete this procedure ? Enter '1' to edit information related to this procedure, or '2' to delete this procedure from your records. NON-O.R. PROCEDURE Select procedure or press RETURN to continue listing procedures: Enter the number corresponding to the desired procedures create a new procedure, or press RETURN to continue listing procedures. If the desired procedure does not appear, press RETURN to continue listing additional procedures , or enter 'NEW' to create a new procedure Press RETURN to continue. >>> The procedure you have selected has a future date. Are you sure you have selected the correct procedure ? Entering a new non-O.R. procedure for Enter the Procedure: Select the Date of the Procedure: The Date of the Procedure MUST be entered. Medical Specialty Are you sure that you want to remove this procedure from your No action taken... Enter RETURN or 'NO' if this procedure should remain on file. Enter 'YES' to delete this procedure. Deleting procedure... Report of Non-OR Procedures How do you want the report sorted ? 1. By Specialty 2. By Provider 3. By Location Enter '1' to sort this report by specialty, '2' to list procedures sorted by provider, or '3' to list procedures sorted by location. Do you want to print the report for all Providers ? YES// Enter RETURN to print the report for all providers, or 'NO' to select a specific provider. Print the Report for which Provider ? REPORT OF NON-O.R. PROCEDURES SRSUR* Do you want to print the report for all Specialties ? YES// Enter RETURN to print the report for all Specialties, or 'NO' to select a specific specialty. Print the Report for which Specialty ? SRSPEC* No procedures for the selected date range. LOCATION NOT ENTERED PATIENT (ID#) LOCATION (IN/OUT-PAT STATUS) FINISH TIME There were no procedures entered for the date range selected. PROVIDER NOT ENTERED Do you want to print the report for all Locations ? YES// Enter RETURN to print the report for all locations, or 'NO' to select a specific location. Print the Report for which location ? SRLOC* SPECIALTY (IN/OUT-PAT STATUS) TALKS CONSTANTLY INITIATES CONVERSATION RESPONDS TO QUESTIONS DOESN'T ANSWER QUESTIONS (FULLY TRAINED) Cultures: Postoperative Consciousness: MEDICAL RECORD | NURSE INTRAOPERATIVE REPORT PAGE Nurse's Signature: SF 509 Progress Notes Case Type: Pat in Holding: Pat in OR: Operation Begin: Pat Out OR: First Assist: Attend Surg:: OR Support Personnel: Scrubbed Valid Consent Confirmed By: Preop Cons: Preop Skin Color: Skin Prepped By: Skin Prep Agent: Second Prep Agent: (FULLY TRAINED) Prosthesis Installed: Irrigation Solution(s): NOT CORRECT, SEE NURSING CARE COMMENTS Sponge Count: Counter:: Adm By: VA ID: Preop Shave By: CLEAN/CONTAMINATED Wound Clssification: Restraints and Position Aids: Electrocautery: Major Minor Operation(s) Performed: Other: Material Sent to Laboratory for Analysis: On: Sponge, Sharps, and Instrument Count Verified As First Verifier: Second Verifier: Packing: Postop Mood: Postop Cons: Postop Skin Integrity: Postop Skin Color: Surgical Nurse Staffing Report Enter RETURN to print the Surgical Nurse Staffing Report for all nurses, or 'NO' to select a specific person. Print the Nurse Staffing Report for which Nurse ? SURGICAL NURSE STAFFING REPORT SRSD* SRED* SRONUR* Normal Daily Schedules for Operating Rooms Enter the name of the operating room: #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### ####################