Enter surgeries and other procedures during the inpatient visit. These entries are included in the patient's discharge paperwork. The information is required; look up None if applicable.
To look up an operation or procedure:
Click Add.
Type at least the first three (3) letters of the operation or procedure. For more than one, you can type criteria for each, separated by commas.
Press ENTER or click Search. Operations and procedures matching your criteria are listed below.
Multiple search parameters will generate multiple sets of results, one for each parameter. Select from one set of results (which may be None of the following) to be presented with the next.
To highlight a result for selection, click its line or press the down/up arrows. Highlight Take as typed to enter the procedure as you typed it. To highlight more than one item, hold down the CRTL key while clicking.
To search using different criteria, click None of the Following, then repeat the previous steps.
Click Add (ALT+A) or press ENTER to select the highlighted items.
Repeat the process until all significant operations and procedures applicable to this visit are listed.
Click OK (ALT+O).
Sign to save the discharge orders. See Signing Discharge Orders.
To display the SNOMED code for an entry, hold the mouse pointer over its row.
Type or select the date the procedure was performed. (The calendar button 
shows when you click the date field.) You can enter the exact date (mm/dd/yyyy), the month and year (mm/yyyy), or the year (yyyy).
Type in the Comments column to include other information such as laterality.
To delete an entry, click its Rmv button (left column).