On the Procedure - Cystourethroscopy template, you can document the details of the cystourethroscopy procedure including the patient position during the procedure, anesthesia provided, antibiotics given during the procedure (if any), procedure findings, post procedure instructions and follow up.
- On the SOAP template, select the Procedures link.
The Procedures template opens.
- In the Genitourinary section, click Cystourethroscopy.
The
Procedure - Cystourethroscopy template opens.
- In the Indication section, do the following:
- Click Description, and select a diagnosis.
- Click Status, and select the diagnosis status from the list.
- To enter a saved default set, click Quick Load and Save.
- 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, click the Consent link.
- In the Procedure section, do the following:
- Select the cystoscope type and enter the french value.
- Select the type of the procedure.
- To select any service item, click Other.
- 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, click Other, and then enter the details.
- In the Patient Position section, select the position of the patient while performing the procedure.
- Enter the details in the following sections.
- Patient Response
- Impression
- Anterior Urethra Findings
- Prostatic Urethra Findings
- Bladder Findings
- Ureteral Orifices Findings
- Follow Up
- Select the Antibiotics Given option.
- If you select Yes, select the details of the antibiotics given from Detail.
- To add other findings, click Other Findings.
- To submit the procedure charges, click Submit to Superbill.
- Click Save & Close.
