NextGen Knowledge Center

Document Excision Procedure Care Details

  1. On the SOAP template, go to the bottom of the template and select the Procedures icon.
    The Udp Procedure Picklist opens.
  2. Click Excision/Repair and click OK.
    The Procedure dermatology excision 1 template opens.
  3. In the Today's Assessment grid, select or add a finding to be excised.
    The Procedure Excision panel is populated with a diagnosis for the selected finding.
  4. In the Procedure Excision panel, do the following:.
    1. Select the appropriate option for Benign or Malignant.
    2. Examine the excision site location with the patient and select the Patient verified site check box.
    3. To document the number of the room in which the excision took place, click RM#.
    4. If collecting a sample for pathology, type the name of the lab in the Path Lab field.
    5. Type the accession number received from the pathology lab in the Accession # if excising a biopsied finding.
    6. To add an indication, select from the Indication 1 picklist or click the blank line and type a non-listed indication.
    7. To add additional indication, click Indication 2.
    8. Enter the name of the surgeon and the assistant.
    9. Select the anesthesia being used from the picklist and enter the amount used in milliliters.
    10. To select the size of the margin in centimeters, click Margin.
    11. Select the Location and Site Specific location.
    12. To add a hemostasis agent, select from the Hemostasis 1 picklist or click the blank line and type a non-listed hemostasis agent.
    13. To add an additional hemostasis agent, click Hemostasis 2.
    14. To add the location of the marking suture on the specimen, click Specimen marking (suture).
    15. To specify the pre and post-operation length and width of the lesion or wound in centimeters, click Pre op size and Post op size.
    16. To specify the diameter of the excision in centimeters, click Excision diameter.