Meditech 6.0 Instructions Documenting Procedure Information

Currently, in 5.54, the Procedure information is located on the Procedure Tab

In 6.0, Procedure information is located in two sections, the General Data section and the Post-Op Data Section within the Operative Record of the Surgical Record.. In order to document Procedure information:

• Select a patient from either the Biller or Nursing Desktop • Highlight the Patient • Click on the Operative Section of the Surgical Record

Once you click on the appropriate section, you will see a listing of sections for documentation purposes

General Data: The General Data section contains the following information.

• Actual Operation Date – you can change the date if needed • Actual Time – you can change the time if needed • Operating Room – you can change the room if needed • Anesthesia Type – this comes from the Anesthesia Dictionary • ASA Class – this comes from the ASA Class Dictionary • Case Type – This can be changed if needed. FYI – we have a custom for “Add

In” which MT is investigating why it did not pull into 6.0 • Pre-Op Diagnosis – clicking the arrow at the end of the line will bring you to a

free text box

Clicking on the will bring you to the F9 lookup (or to time and calendar information)

Post Op Data The Post Op Data section contains the following information.

• Explants – clicking the arrow at the end of the line will bring you to an Explants Screen • Dressings – this pulls from the preference card. You can click on the arrow at the end of

the line to access additional items • Post Op Diagnosis – clicking the arrow at the end of the line will bring you to a free text

box. If there is a Pre-op Dx listed, you can click “Get Pre-Op Dx” to pull that info into the screen

• Actual Procedure – clicking the arrow at the end of the line will bring you to the “Actual Procedure” screen

• Outcome – click on the circle of the Outcome for the procedure. Actual Procedures