Surgical operative notes

Abstract

A computer-implemented method comprising: retrieving a surgical center template for a surgical procedure that is performed by a surgical center; retrieving medical records pertaining to the patient; automatically pre-populating a portion of the template based on contents of the retrieved medical data records; transmitting, to a device used by a physician, the pre-populated template for presentation to the physician; receiving data pertaining to the surgical procedure, wherein the received data comprises at least one of data entered into a predefined data field of the plurality of predefined data fields and data indicative of a selection of a selectable field in the plurality of selectable fields; populating one or more other portions of the template with the received data pertaining to the surgical procedure; and generating, based on the populated template, a surgical operative note for the surgical procedure.

What is claimed is: 
     
         1 . A computer-implemented method comprising:
 retrieving a surgical center template for a surgical procedure that is performed by a surgical center, wherein the surgical center template comprises one or more of (i) a plurality of predefined data fields for entry of medical data, and (ii) a plurality of selectable fields for selection of an attribute of a patient on whom the surgical procedure is performed or an attribute of the surgical procedure;   retrieving medical records pertaining to the patient;   automatically pre-populating a portion of the template based on contents of the retrieved medical data records;   transmitting, to a device used by a physician, the pre-populated template for presentation to the physician;   receiving, from the device used by the physician, data pertaining to the surgical procedure, wherein the received data comprises at least one of data entered into a predefined data field of the plurality of predefined data fields and data indicative of a selection of a selectable field in the plurality of selectable fields;   populating one or more other portions of the template with the received data pertaining to the surgical procedure; and   generating, based on the populated template, a surgical operative note for the surgical procedure, with the surgical operative note comprising a summary of the surgical procedure and one or more details of the surgical procedure.   
     
     
         2 . The computer-implemented method of  claim 1 , wherein the surgical operative note comprises one or more details of an implant or a device used during the surgical procedure. 
     
     
         3 . The computer-implemented method of  claim 1 , wherein generating the surgical operative note comprises:
 structuring the surgical operative note into a plurality of operative portions, each of the plurality of operative portions related to a stage of a plurality of stages of the surgical procedure.   
     
     
         4 . The computer-implemented method of  claim 3 , wherein the plurality of operative portions comprise a consultation portion, a pre-operative portion, an intra-operative portion, a post-operative portion, and a discharge portion. 
     
     
         5 . The computer-implemented method of  claim 1 , wherein the surgical center template comprises:
 pre-operative portion for entry of data pertaining to a time period prior to the surgical procedure;   an intra-operative portion for entry of data pertaining to performance of the surgical procedure;   a post-operative portion for entry of data pertaining to an outcome of the surgical procedure or data related to recovery from the surgical procedure; and   a discharge portion for entry of data pertaining to discharge from the surgical center.   
     
     
         6 . The computer-implemented method of  claim 1 , wherein the surgical center template comprises a visualization related to the surgical procedure, and the method further comprises:
 labeling one or more portions of the visualization based on the medical information included in the medical records pertaining to the patient.   
     
     
         7 . The computer-implemented method of  claim 6 , wherein receiving, from the device used by the physician, data pertaining to the surgical procedure comprises:
 receiving data indicative of an annotation of a portion of the visualization.   
     
     
         8 . The computer-implemented method of  claim 1 , wherein receiving, from the device used by the physician, data pertaining to the surgical procedure comprises:
 receiving data indicative of a barcode associated with an implantable device that is used in the surgical procedure; and   the method further comprises:
 retrieving data associated with the barcode from a data repository; 
 updating a portion of the surgical center template with the retrieved data that is associated with the bar code; and 
 transmitting, to the device used by the physician, the retrieved data for presentation with the surgical center template. 
   
     
     
         9 . The computer-implemented method of  claim 1 , further comprising:
 determining, based on the received data pertaining to the surgical procedure, whether the surgical procedure is in compliance with national medical standards.   
     
     
         10 . The computer-implemented method of  claim 1 , further comprising:
 determining that required data pertaining to the surgical procedure has not been received from the device used by the physician; and   transmitting, to the device used by the physician for presentation to the physician, a notification that the required data has not been received.   
     
     
         11 . One or more machine-readable hardware storage devices storing instructions that are executable by one or more processing devices to perform operations comprising:
 retrieving a surgical center template for a surgical procedure that is performed by a surgical center, wherein the surgical center template comprises one or more of (i) a plurality of predefined data fields for entry of medical data, and (ii) a plurality of selectable fields for selection of an attribute of a patient on whom the surgical procedure is performed or an attribute of the surgical procedure;   retrieving medical records pertaining to the patient;   automatically pre-populating a portion of the template based on contents of the retrieved medical data records;   transmitting, to a device used by a physician, the pre-populated template for presentation to the physician;   receiving, from the device used by the physician, data pertaining to the surgical procedure, wherein the received data comprises at least one of data entered into a predefined data field of the plurality of predefined data fields and data indicative of a selection of a selectable field in the plurality of selectable fields;   populating one or more other portions of the template with the received data pertaining to the surgical procedure; and   generating, based on the populated template, a surgical operative note for the surgical procedure, with the surgical operative note comprising a summary of the surgical procedure and one or more details of the surgical procedure.   
     
     
         12 . The one or more machine-readable hardware storage devices of  claim 11 , wherein the surgical operative note comprises one or more details of an implant or a device used during the surgical procedure. 
     
     
         13 . The one or more machine-readable hardware storage devices of  claim 11 , wherein generating the surgical operative note comprises:
 structuring the surgical operative note into a plurality of operative portions, each of the plurality of operative portions related to a stage of a plurality of stages of the surgical procedure.   
     
     
         14 . The one or more machine-readable hardware storage devices of  claim 13 , wherein the plurality of operative portions comprise a consultation portion, a pre-operative portion, an intra-operative portion, a post-operative portion, and a discharge portion. 
     
     
         15 . The one or more machine-readable hardware storage devices of  claim 11 , wherein the surgical center template comprises:
 pre-operative portion for entry of data pertaining to a time period prior to the surgical procedure;   an intra-operative portion for entry of data pertaining to performance of the surgical procedure;   a post-operative portion for entry of data pertaining to an outcome of the surgical procedure or data related to recovery from the surgical procedure; and   a discharge portion for entry of data pertaining to discharge from the surgical center.   
     
     
         16 . An electronic system comprising:
 one or more process devices; and   one or more machine-readable hardware storage devices storing instructions that are executable by one or more processing devices to perform operations comprising:   retrieving a surgical center template for a surgical procedure that is performed by a surgical center, wherein the surgical center template comprises one or more of (i) a plurality of predefined data fields for entry of medical data, and (ii) a plurality of selectable fields for selection of an attribute of a patient on whom the surgical procedure is performed or an attribute of the surgical procedure;   retrieving medical records pertaining to the patient;   automatically pre-populating a portion of the template based on contents of the retrieved medical data records;   transmitting, to a device used by a physician, the pre-populated template for presentation to the physician;   receiving, from the device used by the physician, data pertaining to the surgical procedure, wherein the received data comprises at least one of data entered into a predefined data field of the plurality of predefined data fields and data indicative of a selection of a selectable field in the plurality of selectable fields;   populating one or more other portions of the template with the received data pertaining to the surgical procedure; and   generating, based on the populated template, a surgical operative note for the surgical procedure, with the surgical operative note comprising a summary of the surgical procedure and one or more details of the surgical procedure.   
     
     
         17 . The electronic system of  claim 16 , wherein the surgical operative note comprises one or more details of an implant or a device used during the surgical procedure. 
     
     
         18 . The electronic system of  claim 16 , wherein generating the surgical operative note comprises:
 structuring the surgical operative note into a plurality of operative portions, each of the plurality of operative portions related to a stage of a plurality of stages of the surgical procedure.   
     
     
         19 . The electronic system of  claim 18 , wherein the plurality of operative portions comprise a consultation portion, a pre-operative portion, an intra-operative portion, a post-operative portion, and a discharge portion. 
     
     
         20 . The electronic system of  claim 16 , wherein the surgical center template comprises:
 pre-operative portion for entry of data pertaining to a time period prior to the surgical procedure;   an intra-operative portion for entry of data pertaining to performance of the surgical procedure;   a post-operative portion for entry of data pertaining to an outcome of the surgical procedure or data related to recovery from the surgical procedure; and   a discharge portion for entry of data pertaining to discharge from the surgical center.