With the Team Chart Concept from Ulrich Medical Concepts , you can document surgeries, and medical procedures fast, accurately, and to a very high standard.

         This page demonstrates how Templates in the Team Chart Concept can be used to quickly document an actual ENT/BMT surgical procedure.

         A typical BMT Template might have five multiple-choice selections as shown here:

         To document the BMT procedure, the surgeon simply clicks, with the mouse, on 1 selection from each group of choices. For example, the first group of choices is (with only 1 choice):

         1. BMT - Procedure Info

         A single mouse click on the above choice inserts the following text into the physician's dictation:

The patient, Mr. John Doe, a 29 year old man, was taken to the operating room, placed in the supine position, and under general mask anesthesia the patient was prepped and draped in the usual fashion. A speculum was introduced into the right external auditory canal and visualization undertaken with the Zeiss operating microscope.

Pretty slick, don't you agree?

         Notice that the patient's name, age and sex were automatically inserted into the dictation.

         Then next group is a choice between:

         2. Anterior inferior myringotomy, or

         2. Posterior inferior myringotomy

         Choosing ' Anterior inferior myringotomy' with one click of the mouse inserts this dictation:

A small amount of cerumen was removed with a cerumen loop and an anterior inferior myringotomy incision made with a myringotomy knife.

         If instead, we had chosen ' Posterior inferior myringotomy' this text would have been inserted:

A small amount of cerumen was removed with a cerumen loop and a posterior inferior myringotomy incision made with a myringotomy knife.

         Continuing on, with 3 more mouse clicks, our Surgery Note is complete, and looks like this:

The patient, Mr. John Doe, a 29 year old man, was taken to the operating room, placed in the supine position, and under general mask anesthesia the patient was prepped and draped in the usual fashion. A speculum was introduced into the right external auditory canal and visualization undertaken with the Zeiss operating microscope. A small amount of cerumen was removed with a cerumen loop and an anterior inferior myringotomy incision made with a myringotomy knife. A large serous effusion was suctioned from the middle ear space, and a Duravent tube inserted into the myringotomy site without difficulty. Cipro HC Otic drops were added to the external auditory canal, a cotton ball added to the meatus and attention turned to the opposite ear where a similar procedure was accomplished with similar findings. The procedure was subsequently terminated. The patient tolerated the procedure well without complications and was transported to the post-anesthesia care unit in stable condition.

         5 mouse clicks. Dictation done. Next patient, please.

         With the Team Chart Concept you can document as fast as you can think.

         It is very easy to build your own Surgery Note Templates. There is no limit as to how many choices you can have, or the detail to which your dictation can go.  And you can automatically insert data such as name, age, addresses, vital signs, prescriptions, referring M.D.'s, allergies, Diagnosis codes, etc.

       If your time is valuable, spend a little time learning about Surgery Notes in the Team Chart Concept from Ulrich Medical Concepts . You'll save a lot of time later.

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