Document Past Surgical History

Introduction

The Past Surgical History command allows the user to document the patient's past surgical history. Past Surgical History can be viewed in the patient summary section of the chart.

Key Objectives

• You will learn how to record a past surgical procedure into a patient's chart.

Video

FAQ:

Q: I made a mistake, how do I remove this command?

A: Commands can be entered in error, but not deleted.  Please review the Entering a Command in Error document for directions.  

Q: How do I print this command?

A: A command can be printed by using the triple dot menu to the right of the command and selecting the print option. 

Step by Step

• Being in an open note of the patient's chart
• Type "past surgical history", "psh", or "surgical" into a blank line within the note
• Select the command by pressing Enter 
• Type the desired surgery or procedure after the command line title and common procedures will populate that match your search.

TIP: If the desired procedure is not populating, the input can be supplied as free text.

• Use Tab or your mouse to navigate through the remaining fields:
  
  • • Approximate Date: the exact date or estimated date of the procedure. (i.e. "2 years ago")
      
    • Comment: any additional comments relating to the surgery such as complications, name of the surgeon, or hospital. Field has a 1000 character limit. 
• Select SAVE to commit the command into the note. The entry immediately becomes under Surgical History in the patient summary on the left hand side.
  
  

Roles

• Provider
• Clinical Staff