308 lines
9.7 KiB
Plaintext
308 lines
9.7 KiB
Plaintext
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English French Notes Complete/Exclude
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Dosage entered incorrectly.
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Dosage must be 1 to 15 characters in length, i.e. 15 mg.
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ENTER DOSE:
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SHORT SCREEN
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POST OPERATION
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SURGICAL STAFF
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REVIEW REQUEST
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An operative procedure must be selected to use this option.
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... Modifier deleted
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CPT Modifier '
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' is not acceptable with this CPT code.
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Answer with PRIN. PROCEDURE CPT MODIFIER
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You may enter a new PRIN. PROCEDURE CPT MODIFIER, if you wish.
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Answer with OTHER PROCEDURE CPT MODIFIER
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You may enter a new OTHER PROCEDURE CPT MODIFIER, if you wish.
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The Morbidity and Mortality Reports include the Perioperative Occurrences
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Report and the Mortality Report. Each report will provide information
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from cases completed within the date range selected.
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Do you want to generate both reports
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Enter '1' to print the Perioperative Occurrences Report, or '2' to print the Mortality Report
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1. Perioperative Occurrences Report
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2. Mortality Report
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MORTALITY REPORT
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No mortalities for the selected date range.
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AUTOPSY (Y/N)
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Annual Report of Non-O.R. Procedures
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Print the report on which Device:
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ANNUAL REPORT OF NON-O.R. PROCEDURES
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TOTAL NON-O.R. PROCEDURES FOR
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TOTAL NON-O.R. PROCEDURES:
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SUMMARY OF ALL SPECIALTIES
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CPT - PROCEDURE
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Reason an Assessment was not Created
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According to your records, an assessment should be created for this surgical
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Do you want to update this information and not create a surgery risk
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assessment for this case ? NO//
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If this case will not be used for the risk assessment study, Enter 'YES' to
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change the status. You will then be prompted for the reason that no assessment
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was done. Enter 'NO' to leave this case unchanged.
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If you delete the reason why no assessment was created for this case, the
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computer will automatically update your records to make this a non-assessed
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Are you sure that you want to delete the reason ? NO//
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By entering an '@', you have told the computer that you want to remove the
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reason why no assessment was created for this case. If this reason should be
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Updating to non-assessed status...
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>>> The patient you have selected died on
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Are you sure this is the correct patient ?
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Entering a new surgical case for
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Select the Date of Operation:
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When entering a new surgery case, a date MUST be entered. If you do not
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know the date of operation, enter this patient on the Waiting List.
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Select Surgeon:
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The person you selected does not have the appropriate keys necessary to be
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entered as a surgeon. Please make another selection.
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Select Surgical Specialty:
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NEW SURGERY
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Do you want to continue ? YES//
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Enter RETURN if you want to re-enter a date and continue creating a new
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case, or 'NO' to leave this option.
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NURSE INTRAOPERATIVE REPORT
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Operating Room:
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Surgical Priority:
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Patient in Hold:
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Patient in OR:
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Operation Begin:
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Operation End:
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Surgeon in OR:
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Patient Out OR:
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First Assistant:
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Attending Surg:
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Second Assistant:
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Assistant Anesth:
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Other Scrubbed Assistants:
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NURSE'S SIG:
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SF 509 PROGRESS NOTES
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Press RETURN to continue with this report, or '^' to return to the
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previous menu.
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MEDICAL RECORD | NURSE INTRAOPERATIVE REPORT PAGE
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OR Support Personnel:
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Circulating
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Other Persons in OR:
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Preop Mood:
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Preop Consc:
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Preop Skin Integ:
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Preop Converse:
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Valid Consent/ID Band Confirmed By:
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NO, SEE NURSING CARE COMMENTS
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Time Out Verification Completed:
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Preoperative Imaging Confirmed:
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Skin Prep By:
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Skin Prep Agent:
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Skin Prep By (2):
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2nd Skin Prep Agent:
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Preop Shave By:
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Surgery Position(s):
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Placed:
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Restraints and Position Aids:
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Electrocautery Unit:
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ESU Coagulation Range:
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ESU Cutting Range:
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Electroground Position(s):
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Major
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Minor
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Operations Performed:
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Other:
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Material Sent to Laboratory for Analysis:
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Specimens:
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Cultures:
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Anesthesia Technique(s):
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Tubes and Drains:
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Tourniquet:
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Time Applied:
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Time Released:
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Site Applied:
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Pressure Applied (in TORR):
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Thermal Unit:
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Prosthesis Installed:
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Medications:
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Irrigation Solution(s):
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Temperature:
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Time On: N/A
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Time Off: N/A
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Time On:
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Time Off:
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Item:
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Lot/Serial Number:
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Sterile Resp:
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Size:
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Time Administered:
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Administered By:
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Time Used:
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Blood Replacement Fluids:
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Sponge Count:
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Sharps Count:
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Instrument Count:
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Counter:
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Counts Verified By:
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Dressing:
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Packing:
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Blood Loss:
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Postoperative Mood:
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Postoperative Consciousness:
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Postoperative Skin Integrity:
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Postoperative Skin Color:
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Type of Laser:
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Sequential Compression Device:
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Wound Classification:
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Discharged Via:
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Nursing Care Comments:
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NO COMMENTS ENTERED
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Source Identification:
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VA Identification:
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Transmit Surgery Risk Assessments
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NON-O.R. PROCEDURE REPORT
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MEDICAL RECORD | NON-O.R. PROCEDURE REPORT PAGE
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Case #:
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PROVIDER'S SIG:
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Non-O.R. Procedures for
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(DIED ON
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Enter the number corresponding to the procedure for which you want to print
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NON-O.R. PROCEDURES FOR
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Med. Specialty:
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Principal Diagnosis:
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ICD9 CODE:
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Patient Status:
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3. ATTENDING NOT PRESENT,
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Att Code:
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BUT AVAILABLE
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Attend Anesth:
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Anesthesia Supervisor Code:
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Anesthesia Technique:
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Diagnostic/Therapeutic (Y/N):
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Anes Begin:
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Anes End:
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Proc Begin:
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Proc End:
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Procedure(s) Performed:
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Procedure Code Comments:
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Indications for Procedure:
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Specimens:
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Provider's Dictation:
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Occurrences:
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NEW PROCEDURE
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' or 'NEW' to create a new procedure
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Do you want to edit or delete this procedure ?
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Enter '1' to edit information related to this procedure, or '2' to delete
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this procedure from your records.
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NON-O.R. PROCEDURE
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Select procedure or press RETURN to continue listing procedures:
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Enter the number corresponding to the desired procedures
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create a new procedure,
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or press RETURN to continue listing procedures.
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If the desired procedure does not appear, press RETURN to continue
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listing additional procedures
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, or enter 'NEW' to create a new procedure
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Press RETURN to continue.
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>>> The procedure you have selected has a future date.
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Are you sure you have selected the correct procedure ?
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Entering a new non-O.R. procedure for
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Enter the Procedure:
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Select the Date of the Procedure:
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The Date of the Procedure MUST be entered.
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Medical Specialty
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Are you sure that you want to remove this procedure from your
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No action taken...
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Enter RETURN or 'NO' if this procedure should remain on file. Enter 'YES'
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to delete this procedure.
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Deleting procedure...
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Report of Non-OR Procedures
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How do you want the report sorted ?
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1. By Specialty
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2. By Provider
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3. By Location
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Enter '1' to sort this report by specialty, '2' to list
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procedures sorted by provider, or '3' to list procedures sorted by location.
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Do you want to print the report for all Providers ? YES//
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Enter RETURN to print the report for all providers, or 'NO'
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to select a specific provider.
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Print the Report for which Provider ?
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REPORT OF NON-O.R. PROCEDURES
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SRSUR*
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Do you want to print the report for all Specialties ? YES//
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Enter RETURN to print the report for all Specialties, or 'NO'
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to select a specific specialty.
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Print the Report for which Specialty ?
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SRSPEC*
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No procedures for the selected date range.
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LOCATION NOT ENTERED
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PATIENT (ID#)
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LOCATION (IN/OUT-PAT STATUS)
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FINISH TIME
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There were no procedures entered for the date range selected.
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PROVIDER NOT ENTERED
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Do you want to print the report for all Locations ? YES//
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Enter RETURN to print the report for all locations, or 'NO'
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to select a specific location.
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Print the Report for which location ?
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SRLOC*
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SPECIALTY (IN/OUT-PAT STATUS)
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TALKS CONSTANTLY
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INITIATES CONVERSATION
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RESPONDS TO QUESTIONS
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DOESN'T ANSWER QUESTIONS
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(FULLY TRAINED)
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Cultures:
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Postoperative Consciousness:
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MEDICAL RECORD | NURSE INTRAOPERATIVE REPORT PAGE
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Nurse's Signature:
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SF 509 Progress Notes
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Case Type:
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Pat in Holding:
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Pat in OR:
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Operation Begin:
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Pat Out OR:
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First Assist:
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Attend Surg::
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OR Support Personnel:
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Scrubbed
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Valid Consent Confirmed By:
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Preop Cons:
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Preop Skin Color:
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Skin Prepped By:
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Skin Prep Agent:
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Second Prep Agent:
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(FULLY TRAINED)
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Prosthesis Installed:
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Irrigation Solution(s):
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NOT CORRECT, SEE NURSING CARE COMMENTS
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Sponge Count:
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Counter::
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Adm By:
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VA ID:
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Preop Shave By:
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CLEAN/CONTAMINATED
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Wound Clssification:
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Restraints and Position Aids:
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Electrocautery:
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Major
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Minor
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Operation(s) Performed:
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Other:
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Material Sent to Laboratory for Analysis:
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On:
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Sponge, Sharps, and Instrument Count Verified As
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First Verifier:
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Second Verifier:
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Packing:
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Postop Mood:
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Postop Cons:
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Postop Skin Integrity:
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Postop Skin Color:
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Surgical Nurse Staffing Report
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Enter RETURN to print the Surgical Nurse Staffing Report for all nurses, or
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'NO' to select a specific person.
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Print the Nurse Staffing Report for which Nurse ?
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SURGICAL NURSE STAFFING REPORT
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SRSD*
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SRED*
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SRONUR*
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Normal Daily Schedules for Operating Rooms
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Enter the name of the operating room:
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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