Document the Hysteroscopy, Ablation, or Sterilization Indication for Procedures

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document the Hysteroscopy, Ablation, or Sterilization Findings Details

You can document the procedure findings in the Hysteroscopy/Ablation/Sterilization panel on the Hysteroscopy - Procedure template. Open the Hysteroscopy - Procedure template, and then expand the Hysteroscopy/Ablation/Sterilization panel. In the Findings section, to document Uterine size, do one of the following: Select the Normal checkbox. Enter a size in Other. Findings section For Position, select anteverted, retroverted, or midline. Enter additional details in Comments.You can also use My Phrases to directly add comments. Parent topic: Open the Template for Hysteroscopy, Ablation, or Sterilization Procedures See also Open the Template for Hysteroscopy, Ablation, or Sterilization Procedures

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document the Hysteroscopy, Ablation, or Sterilization Recovery and Discharge Details

You can document the recovery details of the Hysteroscopy, Ablation, or Sterilization procedure in the Recovery and Discharge Details panel on the Hysteroscopy - Procedure template. Open the Hysteroscopy - Procedure template, and then expand the Recovery and Discharge Details panel. Recovery and Discharge Details panel In Patient tolerated procedure well, select No or Yes. In Complications, select No or Yes.If you select Yes, you must enter comments in the corresponding field. Enter the time in Arrived in recovery.You can manually enter the time, select to enter the current time, or select the to enter the time using the Time Entry template. Optional: Select the Patient ID card given checkbox. Enter the details in Discharge completed by. Enter the details in Patient discharged into the care of and the time Enter a birth control option in the Post procedure interval contraception field. Enter assistant and post-procedure comments. Enter instructions for the patient. You can also select

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document the Hysteroscopy Details

You can document the Hysteroscopy procedure details in the Hysteroscopy/Ablation/Sterilization panel on the Hysteroscopy - Procedure template. Open the Hysteroscopy - Procedure template, and then exapnd the Hysteroscopy/Ablation/Sterilization panel. In the Hysteroscopy Details section, enter the hysteroscope type, size, and distention medium. Hysteroscopy Details section Optional: Select the Gravity feed and Pressure bag checkboxes. Enter the measures for fluid volumes in and out and the fluid deficit. To enter the details for the time scope in and time scope out field, do one of the following: To enter the current time, select . To enter the time using the Time Entry template, select the . Enter the time in Time scope in and Time scope out. If a product is not required for billing, select the *Product not required checkbox. Otherwise, enter the product, lot number, and expiration information in the respective fields. Note: If you have not documented hysteroscopy details or indicated t

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document the Hysteroscopy, Ablation, or Sterilization Post-Procedure Details

You can document the post-procedure details of the Hysteroscopy, Ablation, or Sterilization procedure in the Post-Procedure section on the Hysteroscopy - Procedure template. Open the Hysteroscopy - Procedure template. In the Post-Procedure section, select the procedure and add the applicable modifiers. Post-Procedure section To remove any entered details, you can select Clear . Optional: Select the Bill for surgical tray checkbox. To enter an office-visit follow-up, do one of the following: Enter a time interval in Return to office. The calculated date appears in the date field. Select a date from the calendar in the date field. To schedule a hysterosalpingogram, do one of the following: Enter a time interval in Schedule Hysterosalpingogram. The date is calculated and appears in the date field. Select a date from the calendar in the date field. Select Place Order, and then select Submit to Superbill. When the charges are submitted, a Charges Submitted text appears with a checkbox, and

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document the Hysteroscopy, Ablation, or Sterilization Anesthesia Details

You can document the anesthesia details of the procedure in the Hysteroscopy/Ablation/Sterilization panel on the Hysteroscopy - Procedure template. Open the Hysteroscopy - Procedure template, and then expand the Hysteroscopy/Ablation/Sterilization panel. Optional: In the Anesthesia section, select the No cervical block performed checkbox. Anesthesia section To document a cervical block that is performed, enter the following details: Select an anesthetic agent, anesthetic dose, and a block type. Enter the details of additional anesthesia and medications. The Meds field has a 75 characters limit. Select IV sedation administered, see anesthesia record or No IV sedation administered. Note: If you document in the Cervical block performed section, and then select the No cervical block performed checkbox, the documented cervical block details are cleared. Similarly, if you select the No cervical block performed checkbox, and then enter the cervical block details, the No cervical block perform

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Document the Aldrete Score

You can document the Aldrete score of a patient on the ASC - Aldrete Score template. Open the Hysteroscopy - Procedure template. In the Aldrete Score panel, select Add.The ASC - Aldrete Score template opens. ASC - Aldrete Score template To display the Aldrete Post Anesthetic Score in the Modified Aldrete Post Anesthetic Recovery Score © field, select the applicable options. Activity Respiration Circulation Consciousness O2 Saturation Note: The modified score must be at least 9 to discharge a patient. To display the Aldrete Post Anesthetic Score for Ambulatory Anesthesia in the Aldrete Post Anesthetic Recovery Score © Modified for Ambulatory Anesthesia field, select the applicable options in the following sections. Activity Dressing Respiration Pain Circulation Ambulation Consciousness Fasting - Feeding O2 Saturation Urine Output Note: The Aldrete Post Anesthetic Score must be at least 18 to discharge a patient. Select the Sign off checkbox.The username and current date appear in Comple

Document the Hysteroscopy, Ablation, or Sterilization Indication for Procedures

Recommendations

Document the Hysteroscopy, Ablation, or Sterilization Findings Details

Document the Hysteroscopy, Ablation, or Sterilization Recovery and Discharge Details

Document the Hysteroscopy Details

Document the Hysteroscopy, Ablation, or Sterilization Post-Procedure Details

Document the Hysteroscopy, Ablation, or Sterilization Anesthesia Details

Document the Aldrete Score

Document the Hysteroscopy, Ablation, or Sterilization Findings Details

Document the Hysteroscopy, Ablation, or Sterilization Recovery and Discharge Details

Document the Hysteroscopy Details

Document the Hysteroscopy, Ablation, or Sterilization Post-Procedure Details

Document the Hysteroscopy, Ablation, or Sterilization Anesthesia Details

Document the Aldrete Score