Acute Surgical Procedure Orders and Orders Affiliated Proposing Surgical Procedure Orders and Orders Requesting a Surgical Encounter FIN#: 1. Office calls Pre-registration at 801-387-7646 or 800-624-3972. 2. Be prepared with the following pieces of information: Name, Date of Birth, Phone, and diagnosis or reason for visit. The registration staff will give the clinic the FIN#. The MA/Office staff must stay on the phone until the FIN# is given. Opening the Patient Chart 1. From the home screen, in the upper right corner, click on search field and enter the patient Lastname, Firstname and press Enter. 2. From the Patient Search window you will be able to select the patient and highlight the FIN provided by Pre-registration. Remember to look for the appropriate location, and service (e.g. surgery). Click Ok. 3. If the patient has not had allergies documented in icentra, you will get the Missing Allergies message. Select OK to skip this step. (If you do not get this message you can skip to the next step).
Proposing a Surgical Procedure Order 1. From your Menu Bar, click on Patient Summary and then the Summary Tab. 2. Go to the Procedure/Surgery Request item and confirm that the order type is Inpatient. Click on Shared. 3. Below Shared is a search field showing Provider Last name, First name. Type in the name of the surgeon who is requesting the surgery. Select the folder Surgical Procedures. (This favorite folder must be set up in advance by the provider). 2015 Version 2.3 10/22/2015 Page: 2
4. You will then see a list of the provider s favorite Surgical Procedures. (These favorite procedure will be specific to the unique Doctor Preference Cards used by this provider. These favorite procedures must be set up in advance by the provider). Click on the Order button. 5. Your Orders for Signature box will turn green and show the count of orders you are proposing for the provider. You can add as many unique procedures as desired by the provider. 6. Click on the Orders for Signature box and then click on Modify to fill out the details the scheduler will need to schedule the procedure request. 7. You will then see the Ordering Physician window. Confirm that Proposal is selected. Fill in the ordering provider name. Select a communication type of Signature Required. Click OK. 2015 Version 2.3 10/22/2015 Page: 3
8. Update the Details section of the order by clicking on the procedure line under Non Categorized 9. Fill in all the appropriate fields in the details section and click Sign. Yellow fields are required for placing the order. (If your facility was previously calling or sending a fax to the scheduling office, this is comparable data to what was required when you called or faxed). 10. The procedure request is now routed to the provider s inbox (proposed orders). Once the provider signs the order, it is routed to the surgery scheduling request queue. 2015 Version 2.3 10/22/2015 Page: 4
Acute Surgical Procedure Orders and Orders Affiliated Surgical Area: Facility for Procedure Insurance Primary: Name of Provider Policy Number: Primary Policy number Authorization Number: If known, please fill in. Insurance Secondary: If known, please fill in. Patient Type: Please provide this detail if known. It also drives inpatient only order 1. OP: Going home after surgery, won't be admitted 2. Same Day Admit: coming in day of surgery and will be admitted for 2 day stay 3. Extended Observation: admitted to the hospital and is typically known as 23 hr. stay or op in a bed. Labs Done in Office and Results Sent? Yes or No Due to Device Recall? Yes or No Due to warranty issue? Yes or No AICD? If Yes, model #: If Yes, include Model number. Otherwise, No Pacemaker: Yes or No (This does not take the place of the form used within the OR) Post-Op Pain Management: If needed (ex. Place PCA Post-Op etc.) Surgeon Supplied Implants: Defaults to No. Change to Yes if implants are provided by the surgeon. Primary Surgeon: Required Requested Start: Date you would like the case to be scheduled Primary Procedure: Required. Choose Yes for the Primary Procedure. If additional Procedures are ordered, choose No for the additional procedures. Pre-Op Diagnosis (ICD-10 code): Required, (please type in the actual code, ex. K35, K35.2) Anticipated Anesthesia type: Required Additional Procedure Detail: Required, this should be the same description of the procedure used on the patient surgical consent, ex. Laparoscopic Appendectomy. Special Instructions: Anything to be communicated to the scheduler or the OR regarding the case (ex. Rep name, Surgeon availability, etc.) Modifier 1-2: Not needed if already included in the Additional Procedure Detail Field above. Procedure Duration: Over time this will auto populate with the average time for this procedure. If not populated, please fill in with the number of minutes for the procedure. Setup Duration: Not required Cleanup Duration: Not required Surgeon - Assist: Not needed if already included in the Special Instructions Field above. Surgical Resident: Not needed if already included in the Special Instructions Field above. First and Second Assistant: Not needed if already included in the Special Instructions Field above. Diabetic Patient: Yes or No
Acute Surgical Procedure Orders and Orders Affiliated Proposing a Power Plan (aka Order Set) 1. From your Menu Bar, click on Patient Summary and then the Summary tab. 2. Go to the Procedure/Surgery Request item and confirm that the order type is Inpatient. Click on Shared. 4. Below Shared is a search field showing Provider Last name, First name. Type in the name of the surgeon who is requesting the surgery and press Enter. Select the appropriate provider. Select the folder PowerPlans. (This favorite folder must be set up in advance by the provider). 3. Click on the Order button of the PowerPlan being requested.
4. Your Orders for Signature box will turn green and show the count of the orders you are proposing for the provider. 5. Click on the Order for Signature box and click Sign. 6. You will receive a Route Proposal window. Enter the Physician name in the Review Provider Field and click Ok. 2015 Version 2.3 10/22/2015 Page: 7
7. If the patient has not had allergies documented in icentra, you will get the Missing Allergies message. Select OK to skip this step. (If you do not get this message you can skip to the next step). 8. You will then be taken to the Orders screen where you can review the PowerPlan that has been proposed. Click Sign. 9. The proposed PowerPlan is now routed to the provider s Message Center (proposed orders). Once the provider signs the order, it is now ready for the surgical nurse to initiate when the patient arrives, on the day of surgery. 2015 Version 2.3 10/22/2015 Page: 8