West Los Angeles Veterans Administration Healthcare Center - Orthopaedic Surgery
Notes. Please use the CPRS (Computerized Patient Record System) for all clinical notes. A user ID and Password are needed.
Templates. Template files can be created to ease entry of repeated information, or shared. If you have suggestions for orthopaedic surgery service templates that would be helpful, let me know.
CPT codes. You are asked to enter a code for each patient visit in the clinic. The codes 99212 for a follow up visit, and 99242 for a clinic consultation are used for patients examined by a resident physician. The codes 99243 for consultation and 99213 for follow up would be used for an average complexity patient visit with the staff attending examining the patient.
New consults in the clinic and for inpatients. Since these are tracked by computer using the CPRS application it is helpful if you choose the note title that corresponds to a consultation request. (Please select "Orthopedic Consult Note" not "Orthopedic Clinic Note"). Please present the case to a staff orthopaedic surgeon in the clinic and within 24 hours for inpatients.
Conference Note. Please include an "Ortho case conf presentation note" in CPRS to discuss patients presented during our Wednesday conference.
Operative note. Operative notes should be dictated the day of surgery, and a brief chart note also written. Please select the title ”OPERATIVE <ORTHOPEDIC OPERATIVE NOTE>" in CPRS.
This is a web summary of guidelines for the West L.A. VA Healthcare Center orthopaedic surgery resident physicians. It is intended to make your life easier by gathering information that may be useful into one location.
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