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Internet Driven Form Generator for Brief Op note, Orders, Prescriptions, and Patient Education Sheet.

Problem:
 1) The busy surgeon is faced with a mounting amount of documentation challenges which interferes with already hardpressed time constraints.
(Any surgeon that disputes the increasing amount of documentation is probably not aware of current CMS guidelines).  Most surgeons
are probably not aware of what CMS requires and does not require (and has not felt the sting of a CMS audit).  The other issue is
what does best medical practices require (obviously DVT prophylaxis is not necessary for a carpal tunnel release but is required
for  total knee replacement) and we would want a computerized order sheet to help guide the physician into "best practices".

a) documentation of brief op note (needs to contain all CMS guide lines)
b) patient orders (needs to contain all CMS guides and needs to contain best medical practices).

2) Prescriptions: Most physicians hate to write out multiple prescriptions per patient (typically a patient just gets a script for percocet when
they should actually get percocet, phenargan (for nausea), motrin (for break thru pain), benadryl (for itching), and ambien (for sleep)).
Each of these prescriptions really should be documented, and should be accompanied by a patient education sheet that explains exactly
how and when each of these medications should be given.

3) Patient education:
Again there are medicolegal considerations here.  Patients should all be given a cheat sheet of saftey points and phone numbers to
handle postoperative problems when they get home (for bleeding, shortness of breath ect).

Solution: Use of an Internet driven Form Generator:
Internet form generators are the type of form used by consumers to buy things off of the Internet.  Typically the user, clicks through
several pages and selects objects to buy and and then checks out.  When the final checkout is accomplished, a page is generated that
says thanks for your order, here is what you bought ect..  Also generated is an automated email which gives you the same information.

Goal: To use a form generator to generate: brief op note, patient orders, printed out prescriptions, and patient education forms.

How to Make this Happen:
           - pick specific procedures such as rotator cuff repair and total knee replacement.
- have the generator predict which answers are appropriate so that the surgeon does not have to waste time clicking thru options (for
instance, on the brief op note no one sends out specimens (required CMS item) for a rotator cuff repair and no one orders DVT
prophylaxis, and so therefore, the generator should predict these items.
- it is important that the surgeon needs to spend only second on the program and when the surgeon hits submit all of the information
gets printed out.

a working example exists at: www.orthonc.com/opnote4a.html

 


Original Text by Clifford R. Wheeless, III, MD.

Last updated by Clifford R. Wheeless, III, MD on Sunday, May 4, 2008 2:12 pm