Document Cystourethroscopy Procedures

You can document details of the cystourethroscopy procedure.

1. On the SOAP template, select the Procedures link.
   The Procedures template opens.
2. In the Genitourinary section, select Cystourethroscopy.
   The Procedure - Cystourethroscopy template opens.

   

3. In the Indication section, do the following:
   1. Select Description, and select a diagnosis.
   2. Select Status, and select the diagnosis status from the list.
4. To enter a saved default set, select Quick Load and Save.
5. In the Pre-Procedure Care section, select the appropriate check boxes after explaining the procedure details to the patient.
   Note: To add more information about the consent, select the Consent link.
6. In the Procedure section, do the following:
   1. Select the cystoscope type and enter the french value.
   2. Select the type of the procedure.
   3. To select any service item, select Other.
7. In the Anesthesia section, enter the details of the anesthesia given to the patient.
   • If the procedure is done without anesthesia, select None.
   • If the given anesthesia is not in the list, select Other, and then enter the details.
8. In the Patient Position section, select the position of the patient while performing the procedure.
9. Enter the details in the following sections.
   • Patient Response
   • Impression
   • Anterior Urethra Findings
   • Prostatic Urethra Findings
   • Bladder Findings
   • Ureteral Orifices Findings
   • Follow Up
10. Select the Antibiotics Given option.
    • If you select Yes, select the details of the antibiotics given from Detail.
11. To add other findings, select Other Findings.
12. To submit the procedure charges, select Submit to Superbill.
13. Select Save & Close.