While trying to implement a DCIS Condition diagnosis through surgery in OpenEMR, i’m unable to add a Surgery using Procedure Order. Procedure Order only assists diagnostic and lab tests(using (LOINC Codes) with the results.
My requirement is: to be able to setup and add a surgery using CPT codes. Document post surgery treatment and subsequent discharge summary.
Hello @meenag -
One trait about OpenEMR that can cause confusion is that contributors to the OpenEMR code base come from a wide variety of backgrounds and frequently give some functionality a name that means different things to different people. This is the case with the Procedures module. It is designed to only manage tests and other activities which are performed and which then generate results that are documented and reviewed. Lab tests and results are the most common use but radiology and other imaging procedures are also suitable for that module.
One way to approach your requirement is to see if any of the clinical forms which have been contributed to the OpenEMR project suit your needs, either one by itself or in combination with others. This page in the OpenEMR wiki lists all the contributed forms at the time the article was written, but also has the location in the OpenEMR file structure where all current forms in your version are located. Each entry has a link ‘(pic)’ with which you can see what the form looks like and what information it handles.
https://www.open-emr.org/wiki/index.php/OpenEMR_Contributed_Forms
Yet another functionality that might be useful is the Layout Based Visit (LBV) firms which permit you to create your own clinical forms. Here are links to those:
https://www.open-emr.org/wiki/index.php/LBV_Forms
https://www.open-emr.org/wiki/index.php/Sample_Layout_Based_Visit_Form
And finally, custom service codes will probably need to be created to enter onto the fee sheet, the fees for those surgeries and other related services rendered.
Here is a link describing how to construct those custom fee entries:
https://www.open-emr.org/wiki/index.php/OpenEMR_4.2.0_Fee_Sheet_Custom_Service_Categories
Hope any of that is helpful!
Best regards- Harley