The Clinical Tab of the Surgical Audit Tool allows you to record/reference more-detailed information about the patient's clinical history. This tab is further divided into two sub-tabs; the Clinical (sub) tab and the Co-Morbidities tab.
The Clinical (sub) tab allows you to:
o Grade the patient's physical status in accordance with the American Society of Anesthesiologists (ASA) Physical Status Classification System,
o Add Presenting Problems, either custom-defined or DOCLE A coding system used to standardise data entry, help ensure consistency, and provide a base for use with Drug Interactions and Searching code-based (a database of diagnosis and diseases),
o Add Previous Procedures, and
o Add Comments.
The Co-Morbidities tab allows you to view/modify existing patient health issues and specific drug prescriptions. This information can be populated automatically if a DOCLE A coding system used to standardise data entry, help ensure consistency, and provide a base for use with Drug Interactions and Searching-coded active problem exists in the patient's record, as indicated in the following image.