NextGen Knowledge Center

Document the Excision of a Skin Cancer

On the day of the excision procedure, the intake staff follows a standard intake workflow specifying the specialty as Dermatology and visit type as Surgical Visit. The intake staff records demographic and medical information following the guidelines established by the practice.

  1. On the Home Page - Dermatology template, review the patient information entered by the intake staff.
  2. On the Histories template, review the patient information and add information, if necessary.
  3. On the SOAP template, do the following:
    1. In the Reason for Visit panel, document complete details of the reason for visit or add additional reasons for visits, if necessary.
    2. In the Review of Systems panel, click Derm - ROS, and fill in the details in the Dermatology -ROS template.
  4. On the SOAP template, go to the bottom of the template and select the Procedures icon.
    The Udp Procedure Picklist opens.
  5. Click Excision/Repair.
    The Procedure dermatology excision 1 template opens.

  6. Click the Yes option for the Are you performing a procedure on a biopsy proven malignancy? question.
    The application populates the Today's Assessment grid with the untreated skin cancers for this patient.
  7. Select the appropriate record in the grid.
    The application populates the Procedure Excision panel with the data from the selected record.
  8. In the Pre-Procedure Care panel, after explaining the details of the procedure to the patient select the relevant options.
  9. In the Procedure Excision panel, document the information as appropriate.
  10. In the Repair panel, document the required information.
  11. In the Post Procedure panel, record if complications occurred, select how the patient tolerated the procedure, the suggested time for the follow-up visit and other details.
  12. Click Submit to Procedure Billing.
  13. Click Save & Close.
    The system changes the Tx column from N to B for the record in the Skin Cancer Log Treatment History grid. The application also removes the Untreated Skin Cancer alert, if there are no other untreated skin cancers.
  14. Generate your document.