To record a Procedure against the Admission Record, follow these steps:
- Search for a Patient.
- Click Show.
- In the Main Menu, click Admissions.
- Click the ARN (hyperlink) of the admission (opens the show) screen or click Current Admission link
- From here, scroll down to Procedure > Select New button
- Complete fields using the table below as reference.
Field Name | Pick List Options | Description |
|---|---|---|
Procedure* | ICD10/Generic list | This is a pick list of ICD10 or generic codes that is loaded/managed by your system admin |
Priority* | Auto-populated free text value (integer) | The system auto populates this value - the first diagnosis will be given Priority = 1, the second Priority = 2 and so on. However, you can override this default value and the priority list will re-order itself. |
Clinician | Staff pick list containing providers | Clinician is a HMDS statutory requirement (WA). Refer to your clinical coding expert for more details. |
| Date | The specific date of the procedure. Defaults to admission date. | |
Contract Flag | • Contracted Admitted procedure • Contracted non-admitted procedure | Procedure contract flag is a QHAPDC statutory requirement (QLD). Refer to your clinical coding expert for more details. |
* Indicates mandatory field
7. Click:
a. Save - to add the procedure to the admission
b. Save & Add New - to add the procedure and return to the new screen to add another procedure
c. Cancel - to cancel and save no changes
8. Note: Any equal or lower priority procedure entries will be demoted in priority to prevent duplicate priorities.
