Document Urethral Dilation Procedures

You can document the details of the urethral dilation procedure.

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

   

3. In the Indication section, do the following:
   1. Select Description, and select the diagnosis.
      The code is automatically filled.
   2. Select Status, and select the diagnosis status from the list.
      The gender is automatically filled.
4. To enter a saved default set, select Quick Load and Save.
5. In the Pre-procedure care section, select the appropriate checkboxes after explaining the procedure details to the patient.
   Note: To add more information about the consent, select the Consent link.
6. Select the episode.
7. In the Procedure section, do the following:
   1. Specify the urethral stricture location and size.
   2. Select Patient prepped and draped in the usual sterile fashion.
   3. Select the method by which urethral dilation is performed.
   4. Enter the anesthesia details.
   5. To enter other procedure details, select Other Procedure and Code.
8. Enter the post-procedure and follow-up details.
9. Enter any additional information in Comments.
10. To submit the procedure charges, select Submit to Superbill.
11. Select Save & Close.