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

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