Clinical Tab

 

The Clinical Tab of the Surgical Audit Tool allows you to record/reference more-detailed information about the patient's clinical history. This tab is further divided into two sub-tabs; the Clinical (sub) tab and the Co-Morbidities tab.

The Clinical (sub) tab allows you to:

o       Grade the patient's physical status in accordance with the American Society of Anesthesiologists (ASA) Physical Status Classification System,

o       Add Presenting Problems, either custom-defined or DOCLE code-based (a database of diagnosis and diseases),

o       Add Previous Procedures, and

o       Add Comments.

 


The Co-Morbidities tab allows you to view/modify existing patient health issues and specific drug prescriptions. This information can be populated automatically if a DOCLE-coded active problem exists in the patient's record, as indicated in the following image.