Table of Contents
Gentu offers a comprehensive procedures module, which you may use to make procedure bookings, record your operation notes and outcomes, and review past procedures. All of these options are available through the Clinical tab of the patient record.
Creating a Procedure
There are a few methods to creating a new procedure.
You can either book in the appointment first, then open the appointment and select Add > Procedure. This will create a new procedure record, pulling the operation date and time from the appointment booking.
Alternatively, you can open the patient's file and select Add > Procedure.
Booking and Theatre tab
In the New Procedure window, you'll first be presented with the Booking & Theatre tab:
Typing into the Procedure Name field will allow you to select from a list of suggested procedure names. You can have multiple procedure names selected.
If you do not have all of the information to complete the procedure record, don’t worry; you can come back later to fill this in. At minimum, you'll need to enter a name for the procedure and the name of the provider before you can save.
Other fields of note -
Hospital: You can add or edit hospital details in the Address Book (e.g. Add > Hospital). You will need to select a hospital for the procedure record in order for this procedure to print on the theatre list.
Assistant: Assistants can be added via the Address Book (Add > Practitioner). Ensure that the Assists at Procedures checkbox is ticked.
Anaesthetist: Anaesthetists can also be added via the Address Book, and should have the Anaesthetist speciality selected.
Paediatrician: Anaesthetists can also be added via the Address Book, and should have the Paediatrician speciality selected.
Third Party Claims: If the patient has an active third party claim (e.g. a WorkCover claim) in Patient Details, you can select it here to link it to the procedure. Its details will then print on the theatre list.
Billing Items: Here you can select the billing items you think will be used for the procedure. These will print on the theatre list.
Notes: Any pre-op notes which may be relevant to the patient's procedure. These will also print out on the theatre list.
Once a procedure has been saved to a clinical record, you can view it under the Procedure filter in the clinical tab:
To view or edit an existing procedure record, you simply need to highlight the record, and click on Open.
Booking the Procedure
Once you have filled in as much of the Booking & Theatre tab as you can for the procedure, and the date of the procedure has been confirmed, you can then book the procedure into your Appointment Book. If Gentu detects that the patient has a procedure record saved that does not have any booking information within it, then a “pending procedure” will be created.
To book the procedure, navigate to the relevant day in the Appointment Book, and click into the required cell. In the window provided, select the Procedure tab to fill in the details of the procedure:
You will need to select the relevant procedure from the Pending Procedure drop-down menu, and input the remaining booking information before saving the record. Once you have saved the record, the procedure booking will be inserted into the Appointment Book.
Recording Operation Notes
The Operation Notes tab within the Procedure record provides you with the opportunity to record any information about the procedure that you would like, such as any findings, or how the procedure was performed. To access this after the procedure has been completed, you simply need to highlight the procedure record in the clinical file, click on Open, and enter into the Operation Notes tab.
The Outcomes tab contains a serious of side effects that may occur after a procedure has been completed:
If you need to add an outcome that is not provided as a tick box, you can type your outcome into the field provided. If you have multiple outcomes to add, simply separate them with a comma.
To access this after the procedure has passed, you simply need to highlight the procedure record in the clinical file, click on Open, and enter into the Outcomes tab.
What if I need to delete a Pending Procedure appointment that I have booked?
If you need to reschedule the procedure booking for a patient, then you simply need to click onto the procedure booking in the Appointment Book, or in the Appointments tab in the patients record, and then click onto the Pending button to mark the procedure as pending again:
You can then re-book the procedure when you have confirmed a new date.
I need to change my Procedure booking date to another date and time. How can I do this?
You can change the procedure booking date by clicking onto the procedure booking in the Appointment Book, or in the Appointments tab in the patients record, and changing the date in the Op Date field:
If you need to, you can also adjust the time by changing the value in the Op Time field.
Once you click on Save, your procedure will be moved to the appropriate place in the Appointment Book.
How do I print the Operation Report/Operation Notes?
Once you have finished entering your post-operative notes and saved out, you can highlight the procedure and select the Print button (next to the Open button) to print out a pre-formatted Operation Report.
Can I change the Operation Report template/formatting?
Currently the Operation Report is pre-formatted and not able to be changed. If you did wish to change the look and feel of the operation report, or to print it out with your letterhead (for example), you could consider creating a letter template using the procedure letter references, and printing this out instead of the inbuilt Operation Report. You can add new letter templates via Settings > Letter Templates.