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Document Excision Procedure Care Details
On the
SOAP
template, go to the bottom of the template and select the
Procedures
icon.
The
Udp Procedure Picklist
opens.
Click
Excision/Repair
and click
OK
.
The
Procedure dermatology excision 1
template opens.
In the
Today's Assessment
grid, select or add a finding to be excised.
The
Procedure Excision
panel is populated with a diagnosis for the selected finding.
In the
Procedure Excision
panel, do the following:.
Select the appropriate option for
Benign
or
Malignant
.
Examine the excision site location with the patient and select the
Patient verified site
check box.
To document the number of the room in which the excision took place, click
RM#
.
If collecting a sample for pathology, type the name of the lab in the
Path Lab
field.
Type the accession number received from the pathology lab in the
Accession #
if excising a biopsied finding.
To add an indication, select from the
Indication 1
picklist or click the blank line and type a non-listed indication.
To add additional indication, click
Indication 2
.
Enter the name of the surgeon and the assistant.
Select the anesthesia being used from the picklist and enter the amount used in milliliters.
To select the size of the margin in centimeters, click
Margin
.
Select the
Location
and
Site Specific
location.
To add a hemostasis agent, select from the
Hemostasis 1
picklist or click the blank line and type a non-listed hemostasis agent.
To add an additional hemostasis agent, click
Hemostasis 2
.
To add the location of the marking suture on the specimen, click
Specimen marking (suture)
.
To specify the pre and post-operation length and width of the lesion or wound in centimeters, click
Pre op size
and
Post op size
.
To specify the diameter of the excision in centimeters, click
Excision diameter
.
See also
Record an Excision Procedure
Document Excision Procedure Care Details
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document Excision Repair Details
On the SOAP template, go to the bottom of the template and select the Procedures icon. The Udp Procedure Picklist opens. Click Excision/Repair and click OK.The Procedure dermatology excision 1 template opens. In the Today's Assessment grid, select or add a finding to be excised.The Procedure Excision panel is populated with the diagnosis for the selected finding. In the Repair panel, do the following: To select the type of repair performed, click Repair Type. Select the anesthesia being used from the picklist and enter the amount used in milliliters. To add Undermining details, select the No or Yes option as appropriate. If you select Yes, indicate the size of the undermining in centimeters in the cm field. To add a dermal suture type, select from the Dermal suture 1 picklist or click the blank line, and type a non-listed dermal suture type. To add an additional dermal suture type, click Dermal suture 2. To add an epidermal suture type, select from the Epidermal suture 1 picklist or cl
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Record an Excision Procedure
On the SOAP template, go to the bottom of the template and select the Procedures icon. The Udp Procedure Picklist opens. Click Excision/Repair and click OK.The Procedure dermatology excision 1 template opens. Select No for the Are you performing a procedure on a biopsy proven malignancy? question. In the Today's Assessment grid, select or add a finding to be excised.The Procedure Excision panel is populated with a diagnosis for the selected finding. In the Pre-Procedure Care panel, after explaining the details of the procedure to the patient select the relevant options. Note: To add more information about the consent, select the Consent link. In the Procedure Excision panel, document the required information. In the Repair panel, document the required information. In the Post Procedure panel, record if complications occurred, select how the patient tolerated the procedure, the suggested time for the follow-up visit and other details. Click Submit to Procedure Billing. Click Save & Clos
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document the Repair Details
On the Intake template, select the Specialty as Dermatology and Visit Type as Mohs Surgery Visit. Click the Procedure tab. The Derm Proc Mohs 1 template opens. Go to the Repair panel, and document the following: In the Repair Type field, select the type of repair performed from the picklist. Based on the selections, the panel is updated with additional fields or options. Some of the repair types, for example, Flap, have a second picklist that adds details. To add anesthesia used, select from the Anesthesia 1 picklist. To add additional anesthesia details, click Anesthesia 2. Enter the number of milliliters of the anesthesia used in the mL field. To add Undermining details, select the No or Yes option. If you select Yes, indicate the size of the undermining in centimeters. To add a hemostasis agent, select from the Hemostasis 1 picklist or click the blank line and type a non-listed hemostasis agent. To add additional hemostasis agent, select from the Hemostasis 1 picklist or click the b
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document the Excision of a Skin Cancer
On the day of the excision procedure, the intake staff follows a standard intake workflow specifying the specialty as Dermatology and visit type as Surgical Visit. The intake staff records demographic and medical information following the guidelines established by the practice. On the Home Page - Dermatology template, review the patient information entered by the intake staff. On the Histories template, review the patient information and add information, if necessary. On the SOAP template, do the following: In the Reason for Visit panel, document complete details of the reason for visit or add additional reasons for visits, if necessary. In the Review of Systems panel, click Derm - ROS, and fill in the details in the Dermatology -ROS template. On the SOAP template, go to the bottom of the template and select the Procedures icon. The Udp Procedure Picklist opens. Click Excision/Repair.The Procedure dermatology excision 1 template opens. Click the Yes option for the Are you performing a
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document a Biopsy Procedure
On the SOAP template, go to the bottom of the template and select the Procedures icon. The Udp Procedure Picklist opens. Click Biopsy/Destruction/Shave Removal.The Biopsy/Destruction/Shave - Procedures template opens. In the Pre-Procedure Care panel, after explaining the details of the procedure to the patient select the relevant options. Note: To add more information about the consent, select the Consent link. In the Procedure Care section, select No for Are you performing a procedure on a biopsy proven malignancy?. In the Site Details section, click Procedure and select Biopsy from the resulting list. Select a method. Use the resulting Search window to select the specific condition. Select a Status. Document the Location and Site Specific fields. Click Quantity and select the number of items to be biopsied. Select an Indication. Select the anesthesia being used from the picklist and enter the amount used in milliliters. To add the procedure to the Today's Procedures grid, click Add.
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Enter a Topical Treatment Procedure
Before you begin In NextGen® Adaptive Content Engine, document the Intake staff workflow for an office visit for a dermatology encounter, document the Reason for Visit and enter the patient physical exam details. On the SOAP template, go to the bottom of the template and select the Procedures icon. The Udp Procedure Picklist opens. Click Biopsy/Destruction/Shave Removal. You can also access Biopsy/Destruction/Shave - Procedures template from GET. The Biopsy/Destruction/Shave - Procedures template opens. In the Pre-Procedure Care panel, after explaining the details of the procedure to the patient select the relevant options. Note: To add more information about the consent, select the Consent link. In the Procedure Care panel, document the needed information. Select No for the Are you performing a procedure on a biopsy proven malignancy? question. In the Site Details section, click Procedure, and select Destruction of Benign. To add a method, click Method, and select Cantharone or Chemic
