How to Make a Universal Default

Universal defaults are reports where there is no procedure or diagnosis information, but all other fields are filled out. If a surgeon always administers antibiotic an hour before incision, or "90% says prepped and draped in the usual sterile fashion," this allows the surgeon to focus on just those aspects that are different — Indications, Findings, Operative Description. Whatever procedure (CPT) and diagnoses (ICD) were scheduled will automatically populate the report when choosing the universal default. Then, upon completion, surgeons can save this new report as a procedure specific default. 

1. Log in to OpNote, and go to "Defaults"

2. Select "Create new Default Report" and enter in the name (can be 1 default, universal default, etc.)

3. Skip the Procedure and Dx screens, and click on Edit note on the top. Enter the most common responses that is used in most cases.

4. Hit Save & Exit 3

5. Here you can see what the filled out report looks like (without CPT, ICD, Indications, findings, Operative Description)

6. Next time you wish to use it, select the report from your drop down: