Document an Aspiration or Injection Procedure

In the Joint Aspiration/Injection template, highlight the diagnosis in the grid under Today’s Assessments.
In the Procedure field, click to select a value from list.
Select a Location from the picklists that display for the chosen procedure.
To enter the method used, do one of the following:
- Click the Method field to select a value from the resulting list.
- Click the top, blank row in the picklist to free text an entry in the Method field.
If a specific site was prepped, in the Site Prepped section, select Yes.
To choose a value for how the site was prepped, do one of the following:
- Click the Technique field.
- Click the blank row in the picklist to free text an entry.
To specify the anesthetic provided for this patient, do one of the following:
- In the Anesthetic field, click to select a value from the picklist.
- Click the top row to free text the anesthetic.
Click the mL field to enter a unit value.
To specify the gauge of the needle, do one of the following:
- In the Needle gauge field, click to select a value from the picklist.
- Click the top, blank row to free text an entry in the field.
To specify the method used to confirm needle placement, do one of the following:
- In the Placement confirmed by field, click to select a method.
- Click the blank row in the picklist to free text an entry.
To specify the quality of fluid withdrawn, do one of the following:
- Click the Fluid field to select a type.
- Click the top row to free text the type of fluid.
Enter a numerical value for the (mL) Fluid withdrawn.
In the Sterile Dressing section, select one or both options for Pressure and/or Adhesive.

Note: The Improvement by site and % Improvements fields refer to actions that occur after the procedure and are left blank during the initial documentation.
Click the Details field to free text any additional information regarding the sterile dressing.
If medication was injected, click the first available field under Sort: Medication to select a medication and associated billing codes from the picklist.

Note: Medications displayed in this list are configured on the Data Sets Setup practice template. Combination medications that display in the list (for example, Synvisc - One with dexamethasone) will populate on two separate lines in the grid.
Enter medication details for Total mg, Total mL, Lot, Manufacturer, and Expiration in the corresponding fields.

Note: If a medication is administered, an alert message displays if you do not enter values for the mandatory fields: Medication, Total mg, and Total mL.
Click the Add button.
The item displays in the grid under the Injections section of the template.
Click Verify Charges.
The charges display in the Procedure Billing section.