Dental pre-op H&P
From Guide to YKHC Medical Practices
- Open a note.
- For Type, choose “OR Preoperative History & Physical.”
- For Note Template, choose “Free Text Note.”
- Give the note a title. “dental pre-op” is fine.
- Click OK.
- When the note has opened, type “..dentalpreop”
- Scroll to the top and look at what has autopopulated.
- Anything in blue is a Drop List. You can click on it and choose something there. You can also hit F9 to jump between Drop Lists. You can also just delete the text and put whatever you want.
- Any underscore (_) can be jumped to by hitting F3.
- The problems, allergies, meds, and social history should auto-populate. However, if you see “No qualifying data available,” that means that there is nothing listed for one of those sections.
- The vitals should auto-populate with the most recent set of VS from the current FIN. The OR nurses have been known to document in the wrong FIN, which is why VS sometimes don’t appear in our notes. You can ask them to fix it and then refresh the note, or you can just type them in (often faster!)
- The diagnosis should auto-populate at the end…if it has been entered already.
Review OR for Peds for details concerning the process of completing a Dental pre-op the morning of surgery.
