On the Procedure - Prostate US BX template, you can document the ultrasound findings and biopsy details of the prostate gland.
- On the SOAP template, select the Procedures link.
The Procedures template opens.
- In the Genitourinary section, click Prostate Ultrasound/Biopsy.
The
Procedure - Prostate US BX template opens.
- In the Indication section, do the following:
- Click Description, and select the diagnosis.
The code is automatically filled.
- 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 PSA Information section, enter the prostate-specific antigen and percentage of free prostate-specific antigen.
- Enter the details of the pre-procedure medication, if any.
- Select the digital rectal examination findings.
- In the Anesthesia section, select the anesthesia given to the patient and then enter the lot number and expiry date of the anesthesia.
- If the procedure is done without anesthesia, select None.
- If the anesthesia is not in the list, click Other and enter the anesthesia details.
- In the Ultrasound Findings section, do the following:
- Enter the prostate ultrasound findings.
- Select the appropriate check boxes and options for the following:
- Capsule
- Lesion
- Anterior fibromuscular stroma
- Seminal vesicles
- Bladder
- To enter any other finding, click Other findings.
- In the Biopsy section, select the appropriate check boxes and options to document the details of the biopsy, and enter the number of biopsies performed.
- In the Gold Marker Placement section, enter the number of markers, and the lot number, and expiry date.
- In the Post Procedure and Instructions Provided/Follow Up, select the appropriate check boxes and enter the details.
- To provide additional information, click Comments.
- Click Save & Close.
