Details of any procedures performed on the patient during a consultation can be added to a procedure section of the Progress Notes. The Procedure module uses a subset of the DOCLE A coding system used to standardise data entry, help ensure consistency, and provide a base for use with Drug Interactions and Searching coded list.
1. Select the Progress tab in the patient's clinical record.
2. Click .
The Procedure window
3. Enter the first few letters of the procedure name in the Pick from List (coded) text box. A list of procedures that start with the letters entered is displayed. The list of procedures changes dynamically as text characters are entered or deleted.
4. Double-click the required item from the list of choices. Alternatively you can select from previous procedures or conditions listed in the Existing Past Medical History Items list, or free-type a Procedure into the Free Text (uncoded) text box.
5. Optional Modifications:
o By default, the procedure is marked as Active. To change this, un-tick the Active check box.
o Select either Left or Right or both to mark whether the procedure is for the Left, Right or both sides.
o By default, the check boxes are set so the record is saved in the Past Medical History list and as the primary Reason for visit. Clear these check boxes if required.
o To list this procedure on printed letters and summaries, select the Summary check box.
6. Click to confirm your selections. The information is saved into the Procedure section of the patient's progress notes.