BURN CARE
Resident
Orientation Manual
Produced by Galveston Shriners Burn Hospital and
The University of Texas
Medical Branch Blocker Burn Unit.
Contributors: Sally Abston MD, Patricia Blakeney
PhD, Manubhai Desai MD,
Patricia Edgar RN, CIC,John P Heggers PhD, David N Herndon MD,
Marsha Hildreth RD,
Ray J Nichols Jr. MD
DICTATION SYSTEM
Shriners Hospital For Children
815 Market St.
Galveston, TX 77550-2725
To Dictate: (follow the voice prompts)
1. Enter your 6-digit ID (your dictating #).
2. Enter the 2-digit Work Type (see list).
3. Enter the visit # (FIN) do not enter 0's.
4. Begin dictating after the beep (very faint, please listen).
DEPARTMENTS
|
10 - General Surgery |
14 - Plastics |
| 11 - Ortho | 15 - Otolaryngology |
| 12 - OutPatient/Nursing Svc | 16 - Maxillofacial |
| 13 - Rehab | 17 - Other |
WORK TYPES
| 70 - History & Physical | 74 - Inpatient Progress Notes |
| 71 - Operative Reports | 76 - Outpatient Progress Notes |
| 72 - Discharge Summary | 77 - Radiology |
| 73 - Consults | 78 - Perioperative Note |
| 81 - Path Note |
To dictate another report, press "5" and repeat from step 3. Please press "9" to disconnect at the end of your dictation session.
If you wish to change from Dictate to Report Review, after you have pressed "5" to end your current dictation, press "#" then "1". Listen to the voice prompts for Review choices.
To change from Report Review to Dictate, press "#" then "2".
To Insert Text:
1. Press "4" to pause at the point where you
wish to insert text.
2. Press "#" then "6" to switch to the insertion mode. Dictate
the new text.
3. Press "3" to rewind and verify the change.
Lanier Keypad Functions
|
1 |
2 Record |
3 Short Rewind |
| 4 Pause |
5 Next Report |
6 Insert |
| 7 Fast Forward to End |
8 Rewind to Beginning |
9 Manual Disconnect |
| * Clear ID |
0 Not Used |
# Shifted Functions |
FORMAT FOR DICTATION
Discharge Summary:
When dictating the discharge summary, please indicate your name and
title, the staff physician's name, the date of admission, date of discharge
and the patient unit history number.
* Chief Complaint
* History of Present Illness
* Physical Examination
* Diagnostic Laboratory and X-Ray Findings
* Hospital Course
* Operations (include date, pin insertions, and donor site)
* Final Diagnosis
* Condition on Discharge (this should be compared to the admission
status)
* Disposition (include special instructions for wound care)
a) Medications
c) Physical Activity
b) Diet
d) Follow-up and Plan
Operative Reports:
When dictating operative reports, please indicate your name and
title, the staff physician's name and any assistants present during the
operation, the date the procedure was performed and the patient unit history
number.
* Pre-Operative Diagnosis
* Operation (name of procedure performed)
* Post-Operative Diagnosis
* Indications
* Operative Findings
* Procedure (detailed explanation)
* Estimated Blood Loss
* Sponge and Needle Count
* Condition of Patient on Transfer
* Cm2 skin excised