Procedure/Surgical Hx Free Text

Q: Is there any way to free text a surgical procedure anymore? I have a patient who just underwent what the operative report says was a transobturator midurethral sling. ...and I searched transobturator, urethral, midurethral and came up with nothing.

A: There have been a number of requests for docs and other clinical folks to be able to enter procedures and surgeries that just don't seem to be searchable through the Histories tool. You might recall that we have this option in the Problem List, among other places, though discourage people from using free text since uncoded data are not especially versatile. This is the say that such entries would not be easily converted from one tool to another (Problem to Diagnosis List, for example). Also, we have trouble tracking and mining uncoded data for registry and research purposes. That said, when I received the above request, I contacted my IS buddy, Julie Gentes, and, with the flip of a switch:

Uploaded on authorSTREAM by nrk99

Procedure Titles and Codes

I've been asked how the Procedure Hx selection can be made easier when there seem to be hundreds of choices that seem to account for all the esoterica and none of the run-of-the-mill. So I went back to my screen and cracked open the the couple of folders listed in my Favorites section and took a look. There, I found system-tracked entries as well as my favorites from the retired Procedure Profile tool. I then went to the search box and started hunting around. The following table contains 22 of the most common procedures performed, including 2 entries for retinal exams.

Procedure	Code	Terminology
Diagnostic Colonoscopy	269810011	SNOMED
Colonoscopy, flexible…with or without collection…	45378	CPT4
Bone Density scan	456435014	SNOMED
Echocardiogram	1229672017	SNOMED
Carotid Artery Doppler assessment	1488435015	SNOMED
Diagnostic ultrasound of abdomen and retroperitoneum	2838019	SNOMED
CT of Chest	262405017	SNOMED
PFT- pulmonary function tests	1223095017	SNOMED
Polysomnogram	100605013	SNOMED
Upper GI endoscopy…diagnositic…with or without specimens	43235	SNOMED
Myocardial perfusion imaging…at rest and/or stress (exercise and/or pharmacologic)	78465	SNOMED
Exercise stress test	375609014	SNOMED
Exercise stress echocardiography	375982017	SNOMED
MRI of lumbar spine	361784019	SNOMED
MRI of cervical spine	361781010	SNOMED
Cardiac catheterization	70051019	SNOMED
Percutaneous angioplasty of coronary artery	1219586014	SNOMED
Percutaneous coronary intervention	2535176014	SNOMED
Percutaneous transluminal balloon angioplasty with insertion of stent into coronary artery	2694928017	SNOMED
Percutaneous transluminal coronary angioplasty, multiple vessels	141011017	SNOMED
Dilated retinal eye exam…(DM)	2022F	CPT4
Examination of retina	410663011	SNOMED

When searching for these and other Procedures, make sure to have the dropdown windows read Contains and Terminology. I have my terminology selected at SNOMED and CPT4. In order to make changes to that selection, click on the Show Advanced Options term.

Back to blogging

It has been quite a couple of weeks for all of us, no doubt. I have learned a tremendous amount, not only about the new CIS interface (some would call it the Enhanced View), but also about fielding both constructive and... let's just say, not-so-constructive critique. As I hope you've experienced and heard, the CIS team has done an unbelievable job of preparing, deploying and supporting what it takes to make for a system-wide rollout. As we now know, there are deficiencies to the enhancements and folks have not been shy to point them out. I can personally say that I have logged dozens of issues with Cerner, most pertaining to the new prescribing process and the problem/diagnosis lists. While we can do some of the fixes locally, I believe we have the attention of Cerner and will be able to make some improvements over the coming weeks.

You may have heard about or participated in a webinar I ran today during the noon hour. I hope it was useful and plan to do another one next Wednesday at noon. I will be focusing on the Medication List and Prescription Writer and, if we have time, will touch on documentation.

I've made these three videos to review the Procedure/Surgical Hx function. One is for entering a surgical procedure, another for an obstetrical delivery and the last for a routine colonoscopy. They run 3-5 min each.

Surgical Hx This view appears to be truncated for no particular reason. I think you'll get the idea though (and it takes 2-3 hours to make these!)

Obstetrical Hx

Screening Colonoscopy