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Clinical procedures

Explain with AI

This section details how to document and manage clinical procedures performed on patients within 4Geeks Health. Clinical procedures encompass a wide range of medical interventions, from minor in-office procedures to major surgeries.

What is a Clinical Procedure?

In 4Geeks Health, a Clinical Procedure record represents a specific medical intervention performed on a patient. This could include:

  • Surgical Procedures: Operations, biopsies, endoscopies, etc.
  • Diagnostic Procedures: Imaging studies (X-rays, CT scans, MRIs), cardiac stress tests, etc. (Note: These may also be managed through the Laboratory/Imaging modules).
  • Therapeutic Procedures: Injections, wound care, physical therapy sessions, etc.
  • Minor Procedures: Suturing, incision and drainage, etc.

Accessing Clinical Procedures

You can typically access Clinical Procedures in the following ways:

  1. From the Navigation Menu:

    • Look for a “Procedures,” “Clinical Procedures,” or similar option in the main navigation menu.
    • Click this option.

  2. From a Patient Record:

    • While viewing a patient’s record, there may be a section for “Procedures,” “Clinical Procedures,” or a related tab.
    • You might find a button to create a new procedure record for that patient.

  3. From an Outpatient Visit or Inpatient Encounter:

    • Within the context of a visit or encounter, there may be a section or button to add a procedure.

Creating a Clinical Procedure Record

1. Initiate the Process

  • Navigate to the Clinical Procedures section using one of the methods described above.
  • Click a “New Procedure,” “Add Procedure,” or similar button.

2. Fill Out the Procedure Form

The Clinical Procedure form will likely include the following fields:

  • Patient *: Select the patient from the patient list. Mandatory.
  • Practitioner *: Select the healthcare provider who performed the procedure. Mandatory.
  • Procedure Date and Time *: The date and time the procedure was performed. Mandatory.
  • Procedure Type/Code *: Select the type of procedure from a predefined list (e.g., “Appendectomy,” “Colonoscopy”). This list should ideally be linked to standard medical coding systems (e.g., CPT, ICD-10-PCS). Mandatory.
  • Procedure Site (if applicable): Specify the body part or location where the procedure was performed (e.g., “Right knee,” “Left arm”).
  • Anesthesia (if applicable): Record the type of anesthesia used (e.g., General, Local, Regional).
  • Findings: Document the findings of the procedure (e.g., “Normal colonoscopy,” “Presence of polyps”).
  • Complications (if any): Record any complications that occurred during or after the procedure.
  • Notes: Add any additional notes about the procedure.
  • Status: Set the status of this procedure.
  • Attachments: Attach relevant documents (e.g., operative reports, images, pathology reports).

3. Saving the Record

  • Review: Double-check all entered information for accuracy.
  • Save: Click the “Save,” “Create Procedure,” or similar button.

Managing Clinical Procedure Records

  • View: Find and open existing procedure records from the Clinical Procedures list or from the patient’s record.
  • Edit: You may be able to edit certain fields in the procedure record (e.g., to add notes or correct errors). However, some fields (like the procedure date and time) may be locked after the record is created.
  • Print: You may be able to print a summary of the procedure record.
  • Link to Encounter: If the procedure was performed as part of an outpatient visit or inpatient encounter, it should be linked to that encounter record for a complete clinical picture.

Reporting and Analytics

4Geeks Health may provide reporting capabilities to analyze procedure data, such as:

  • Procedure Volume: Track the number of procedures performed by type, practitioner, or department.
  • Complication Rates: Monitor complication rates for different procedures.
  • Billing and Coding: Generate reports for billing and coding purposes.

Important Considerations

  • Standardized Coding: Use standardized medical codes (CPT, ICD-10-PCS) whenever possible to ensure accurate billing and data analysis.
  • Documentation Standards: Follow your organization’s documentation standards for clinical procedures. This may include specific templates or required fields.
  • User Permissions: Different user roles may have different levels of access to create, edit, and view procedure records.
  • Integration: Clinical procedures are often integrated with other modules, such as Patient Records, Appointments, Outpatient Visits, Inpatient Encounters, Laboratory, and Billing.
  • Training: Provide adequate training to staff on how to properly document and manage clinical procedures within 4Geeks Health.

This documentation provides a comprehensive overview of managing clinical procedures in 4Geeks Health. Remember to adapt any specific field names, button labels, or steps to match your organization’s customized configuration and specific workflows.