When it comes to performing an operation, being detailed, precise and accurate is vital. The same comprehensive conciseness applies for documenting an operation within Genie. Genie’s procedure records will allow you to methodically, easily and intuitively record a procedure at each key stage.
Before you begin
You will want to make sure any relevant hospital that your procedures are being performed at have been added into Genie via the Appointment Preferences. You'll also want to ensure any other practitioners who were part of the procedure, such as Assistants, Anaesthetists or Paediatricians, have a record in the Address Book. Also consider whether you will be using, or are already using, ICD/ICPC coding.
There are a couple of reasons why you might want to book a patient's procedure directly from their Clinical window.
You may need to perform a minor procedure on the day, and won't have a previously booked appointment and procedure for this, but still need this documented in your patients record.
You may be consulting a patient and want to pre-book a procedure for them without the hassle of leaving the clinical window to add this, or you may need to add a procedure for a patient, but haven't quite set the date for this yet, so want to mark the procedure as pending.
Regardless of the reason, whenever you’re in a patient's Clinical window, you can add any type of procedure by navigating to Tools > Add Procedure.
Adding a Procedure record that isn't linked to a specific appointmentYou can add a procedure record from the Clinical window for a recent procedure, that doesn't have a specific appointment within your Appointment Book and doesn't require an appointment. Navigate to Tools > Add Procedure. Within the Procedure window enter the relevant information then ensure Needs an Appointment is unticked and click OK.
Adding a Procedure record that is linked to a specific appointment
If you're in a patients Clinical window, and you need to book a procedure at a future date, you can do this easily by navigating to Tools > Add Procedure. Within the Procedure window, enter the relevant information, enter the date and time for the procedure, tick Needs an Appointment and the OK button will change to Make Appointment.
Once you select Make Appointment, an appointment will be created with the relevant procedure and added to the Appointment Book at the specified date and time.
Adding a Pending Procedure from the Clinical window
Another benefit of adding a procedure from the Clinical window is that the procedure can then be marked as pending. This can be particularly useful if you know the patient needs to get a specific operation done but can't commit to a date for this just yet. To mark a procedure as pending, navigate to Tools > Add Procedure, enter the relevant information for this procedure, tick Needs an Appointment, the OK button will change to Appointment Pending.
Once you've clicked Appointment Pending, the procedure will be saved to the patient's Clinical file and it will appear in the Contact List. The 'Pending' nature of the appointment and will be identified by the [P] next to the procedure name in the Contact List. You can then link this procedure to an appointment at a future date, once this has been confirmed with the patient.
A list of all pending procedures can be found by navigating to Appts > Pending Procedures.
When adding a procedure via the Appointment Book the process you follow will depend on whether you're linking an existing pending procedure to an appointment, or booking a brand new procedure for this patient.
Booking a new procedure from the Appointment Book
To book a new procedure from the Appointment Book, begin by entering an appointment for the patient at the start time for the procedure. If this appointment already exists, highlight the appointment then click the Procedure icon on the left-hand side of the Appointment Book.
Within the subsequent Procedure window enter all the relevant details for this procedure, then click OK.
Booking a Pending Procedure from the Appointment Book
To link an existing Pending Procedure for a patient to an appointment within Genie, begin by entering an appointment for the patient within the start time for the procedure. If this appointment already exists, highlight the appointment then click the Procedure icon on the left-hand side of the Appointment Book. As the patient has a Pending Procedure, you will be presented with the following window:
Upon clicking Link, the Procedure window containing all the details entered within the pending procedure will open. Make any required changes to the procedure then click OK.
The Details tab
With the exception of the Provider field and Procedure Name, the level of detail the you wish to go into when adding a procedure is almost entirely up to you. For the sake of future reporting, it is important that you try and keep data entry as consistent as possible across all of your procedures. The fields available in the Details tab are to be utilised at the your discretion and will populate into other areas such as Theatre Lists, Audit Reports and can be used as specific references within your letter templates.
You can add a Procedure name into the Details tab by either typing directly into the text field, or selecting a previously used Procedure name from the icon to the left of Procedures. You can add procedure names to your list of common procedures by typing in the relevant procedure name then clicking the Add to Menu button. For any entries you do not want in the drop- down menu, you can use alt+click to remove them.
If you aren't using ICD10 or ICPC coding, you can enter the procedure name in as free text. If you are using ICD10 or ICPC coding, type a relevant keyword to search. If this procedure involves multiple operations, just enter the major one, and type the remaining procedures in as free text.
Procedure Type should be selected if you intend to use the Quotes section.
Anaesthetic and Prosthesis information added will print on the Theatre List.
The Provider field will be filled when booking a procedure into the Appointment Book, or if the record is created by the provider themselves.
Other optional functions to apply when adding a procedure include:
Add to Past Hx - will add this procedure to the patient's Past History list in their Clinical window and is helpful with consistency of patient information.
Click on the Blue Plus sign button to the right of Pre-Op dx or Post-Op dx field. This will add the diagnosis to the patient's Current Problems list.
Any Pre-op notes you make will print on the Theatre List. You can utilize the "Templates" function here to add notes that may pertain to multiple patients or surgeries. Otherwise, you can freely type whichever notes you wish to, for the use of the hospital and the practice's reference. The various tick boxes within this window can be used for the Pre-op Notification.
Clicking on the WC Info button allows you to select a Workcover claim relevant to the patient. It then inserts the claim number, injury date, employer and insurer details into the Pre-Op Notes field.
When you click on the Assistant, Anaesthetist, or Paediatrician fields, Genie searches your Genie Address Book for doctors who have been assigned this speciality. If it finds any, you will be given a list of matching records from which to select.
The Left or Right tick boxes allow you to specify which side of the body the procedure pertains to, and you can add your own criteria to the Category, Magnitude, and Infection Risk fields if relevant.
The Hospital drop-down list is determined by the 'Rooms' entered in Genie. You must configure these rooms in the Column Order and Rooms tab in Appts > Appt Preferences. A Hospital must be assigned for the procedure to be included and printed on the Theatre List.
Making a selection from the Surgical Performance drop-down list will take you to the Surgical Performance website: www.surgicalperformance.com. (Please note that Genie Solutions has no affiliation with this organisation.)
The Quotes tab
The Quotes tab is a window which allows you to create a quote for the patient, based on the item numbers expected to be charged for the procedure. The Quote tab is discussed in more detail in the Preparing Quotes article. Likewise, the process of generating quote letters for patients is discussed in detail in the Quote Templates article.
The Op Notes tab
This is where you'll come to record information relating specifically to what occurred during the procedure.
Findings, Technique, and Post-op information can be entered into the procedure record via the Op Notes window.
In the upper right section of this window you can add a Checklist for the procedure by clicking the blue plus under Operation Reports/Checklists. You may wish to use the checklist as a replacement to your standard operation report, or have specific checklists relating to specific complications and outcomes.
At the bottom of the Op Notes tab, there are a range of checkboxes covering a variety of common complications. Some are general such as post-op infection, others are speciality-specific such as 'T-zone Breakdown' for Plastic Surgeons and 'Bile Leak' for general surgeons.
When you tick a checkbox, a summary of complications populates into the Audit Summary field.
As well as the supplied complications, you can add any other complications using the Other Complications menu, via either the drop- down functionality or typing free text into the fields.
All complications can be reported in within your own Custom reports, or used to help you Audit your procedures, and find patients who have suffered specific complications.
Within Genie it's possible to create specific Procedure Templates that allow you to quickly pre-fill some of the standard information that will remain the same for the procedure regardless of the patient.
What can I save in a Procedure template?
Procedure templates save the standard information that will likely remain the same each time you perform that specific procedure. The information that you can save into your procedure templates are:
- Procedure name
- Pre-Op diagnosis
- Post-Op diagnosis
- Pre-op notes
- Item Numbers
- Op notes
How can I create a procedure template?
To create a procedure template to use on your regular procedures, you'll simply need to have a Procedure open that has all the relevant information listed above. This can be for a real patient or for a test patient you may have in your system.
Once you've got the required information entered, as outlined above, simply click the Save Template button.
You'll be asked to provide the template a name, by default this is going to be the name of the Procedure.
Once you've clicked OK, you can then load this template into the Procedure window for any patient having the same procedure performed.
How can I use a procedure template?
If you have an existing Procedure template and you're wanting to use this for an upcoming procedure for one of your patients, begin by opening the procedure window for that patient. Before entering any information, hit the Load Template button at the bottom of this window. You'll be presented with the following Select a template... window.
Select the required procedure and click Open.
If you think somebody else would appreciate reading this article feel free to email them a link.