Document Endometrial Biopsy Procedures

You can document the endometrial biopsy procedure details using the Endometrial Biopsy-Procedure template.

1. On the SOAP template, select the Procedures link.
   The Procedures template opens.
2. In Genitourinary, select Endometrial Biopsy.
   The Endometrial Biopsy - Procedure template opens.

   

3. In the Pre-Procedure section, do the following:
   1. Select the last menstrual period in LMP.
      Note: If the LMP is entered on the Vital Signs template, LMP appears automatically in the field.
   2. Optional: Select the Menopausal check box.
   3. Select the pre-op contraception method.
   4. Optional: Select the following check boxes.
      • Correct patient is identified
      • Procedure/risks were explained
      • Questions were answered
      • Consent was obtained
      • Correct side and site confirmed
      • Negative pregnancy test
   5. Select the respective pre-procedure medications and its dosage.
   6. To document the consent details, select the Consent link.
4. In the Procedure section, do the following:
   1. Select a diagnosis in Indication for procedure.
   2. Select a diagnosis status in Status.
   3. Enter the details for the following:
      • Cervix cleaning and prepped using
      • Tenaculum/clamp site anesthetic and its Dose
      • Tenaculum/clamp placed at
      • Paracervical block anesthetic and its Dose
      • Intracervical block anesthetic and its Dose
   4. Optional: Select the The cervix was dilated, The uterine cavity was sounded, and The endometrial cavity was curetted for tissue sampling check boxes.
      You can enter the uterine cavity sound measurement in the given field.
   5. Select the appropriate endometrial biopsy option.
   6. If the procedure cannot be performed, select the Unable to perform procedure due to check box, and then enter the reason.
5. In the Findings section, do the following:
   1. Select the Specimen sent to pathology or Unable to obtain sufficient sample option.
   2. Enter the details in the following fields.
      • Size of Uterus
      • Cervix
      • Adnexa
      • Tissue Specimen
6. In the Post-Procedure section, do the following:
   1. To indicate the patient tolerated the procedure and discharged from the office, select the check box.
   2. Optional: Select The Patient tolerated the procedure and was discharged home from the office check box.
   3. Select the Discharge instructions provided check box if needed.
   4. Enter any additional comments.
   5. Select the procedures and add the applicable modifiers.
   6. Select the number of days or weeks for the follow-up checkup or the date.
      Note: If you select the time interval for the next checkup, the date automatically appears in Date.
7. Select Submit to Superbill.
8. Select Save & Close.