Past Procedures Encounter Section

Within an encounter’s Subjective section, there is an optional Past Procedures encounter section that can be utilized. If the chart has any known past procedures, the procedure will display in a bulleted list on the left hand side of the encounter section. The procedure name will display first, along with the date of the procedure if it was documented. Any notes added on the procedure will display after the date. Hover over the procedure name to display additional options.

Any past procedures that already exist as documented on the chart, appear in the Past Procedures encounter section.

Past Procedures Right Side Quick List Method

A banner or bookmark icon is located on the right side of the Past Procedures encounter section. This can be clicked to expand open to utilize the right side quick list functionality for the Past Procedures section.

Add Past Procedures

From the Past Procedures section, using the right side Quick list method, a search is available to search for a specific preconfigured past procedure within the library you are set to, or click the + icon can be used to document a Past Procedure to the encounter visit.

Using the + icon will display an Add Past Procedures pop-up window to enter in details of the desired past procedure.

• Procedure: use the autocomplete to select a specific procedure that the system offers and stores. This field does allow freetext, but it is recommended (for reporting purposes) to utilize the autocomplete field of choices.
• Date: This field is optional, but can designate a specific date this procedure was done on. If you enter in only a year, the system will assume 1/1 as the month & day.
• Notes: This field is optional, but can free text notes regarding the past procedure. These notes are visible within the encounter & stored encounter document.

In the below example, a past procedure for the patient was a knee replacement done in year 2011 for their left knee.

Once saved, the past procedure displays in the Past Procedures encounter section (and/or in smart plan section) in a bulleted list with the past procedure, target indicated, and the ‘by’ date (next date).

Quick List - Library

The Past Procedures right side quick list method allows you to select Past Procedures that are preconfigured on the Library chart you are currently set to on the encounter or are set to within this specific Past Procedures section.

The encounter in its entirety can be set to a specific chosen Library, or the Past Procedures encounter section can be set to a specific library. If the chosen library has Past Procedures preconfigured to it, those past procedures will display as Quick List selections. Please refer to the Libraries guide for more detailed information.

Blue icon

A checkmark blue circle icon next to an item on the Past Procedures right side quick list method signifies that past procedure selection has already been applied to the encounter section on the chart.

Options

A past procedure has option buttons. One can edit a past procedure, delete a past procedure, rearrange the display order of past procedures in that section, or generate a task about/related to that past procedure.

Past Procedures cannot be marked as historical, nor as archived. Past Procedures are meant to stay with the chart for a lifetime. Currently, there is no reporting around Past Procedures in a system.

Reporting

There is a Past Procedures report available within the Reports sidemenu tab. This is a system wide searchable report that lists stored past procedure history documented in charts. Date range is required for successful report output.

Encounter Stored Document

The Past Procedures encounter section does become part of the encounter visit note document once closed and archived.

Visit Summary

If the encounter is configured to generate a Patient Clinical Visit Summary upon close & archive, the past procedures encounter section contents will be included in that Patient Clinical Visit Summary document.

The Clinical/Visit Summary is a standard additional view that is generated on encounters upon close & archive. This additional view for the Clinical (Visit) Summary is configured in the Encounter Exams editor.

The Patient Clinical Visit Summary has been updated to make it more uniform, compact, and easier to read as a handout given to the patient (or shared to the portal) on the conclusion of their visit. The updated Visit Summary uses 3 main layouts of: Clinical Summary, Vitals, & Vitals_list to populate the contents and includes the Past Procedures encounter section.