Document the Hysteroscopy, Ablation, or Sterilization Indication for Procedures

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Document the Hysteroscopy, Ablation, or Sterilization Findings Details

You can document the procedure findings in the Hysteroscopy/Ablation/Sterilization panel on the Hysteroscopy - Procedure template. Open the Hysteroscopy - Procedure template, and then expand the Hysteroscopy/Ablation/Sterilization panel. In the Findings section, to document Uterine size, do one of the following: Select the Normal check box. Enter a size in Other. Findings section For Position, select anteverted, retroverted, or midline. Enter additional details in Comments. You can also use My Phrases to directly add comments. Parent topic: Open the Template for Hysteroscopy, Ablation, or Sterilization Procedures Related tasks Open the Template for Hysteroscopy, Ablation, or Sterilization Procedures

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Document the Hysteroscopy, Ablation, or Sterilization Anesthesia Details

You can document the anesthesia details of the procedure in the Hysteroscopy/Ablation/Sterilization panel on the Hysteroscopy - Procedure template. Open the Hysteroscopy - Procedure template, and then expand the Hysteroscopy/Ablation/Sterilization panel. Optional: In the Anesthesia section, select the No cervical block performed check box. Anesthesia section To document a cervical block that is performed, enter the following details: Select an anesthetic agent, anesthetic dose, and a block type. Enter the details of additional anesthesia and medications. The Meds field has a 75 characters limit. Select IV sedation administered, see anesthesia record or No IV sedation administered. Note: If you document in the Cervical block performed section, and then select the No cervical block performed check box, the documented cervical block details are cleared. Similarly, if you select the No cervical block performed check box, and then enter the cervical block details, the No cervical block perf

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Document the Hysteroscopy, Ablation, or Sterilization Recovery and Discharge Details

You can document the recovery details of the Hysteroscopy, Ablation, or Sterilization procedure in the Recovery and Discharge Details panel on the Hysteroscopy - Procedure template. Open the Hysteroscopy - Procedure template, and then expand the Recovery and Discharge Details panel. Recovery and Discharge Details panel In Patient tolerated procedure well, select No or Yes. In Complications, select No or Yes. If you select Yes, you must enter comments in the corresponding field. Enter the time in Arrived in recovery. You can manually enter the time, use to enter the current time, or select the down arrow to enter the time using the Time Entry template. Optional: Select the Patient ID card given check box. Enter the details in Discharge completed by. Enter the details in Patient discharged into the care of and the time Enter a birth control option in the Post procedure interval contraception field. Enter assistant and post-procedure comments. Enter instructions for the patient. You can a

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Document the Aldrete Score

You can document the Aldrete score of a patient on the ASC - Aldrete Score template. Open the Hysteroscopy - Procedure template. In the Aldrete Score panel, select Add. The ASC - Aldrete Score template opens. ASC - Aldrete Score template To display the Aldrete Post Anesthetic Score in the Modified Aldrete Post Anesthetic Recovery Score © field, select the applicable options. Activity Respiration Circulation Consciousness O2 Saturation Note: The modified score must be at least 9 to discharge a patient. To display the Aldrete Post Anesthetic Score for Ambulatory Anesthesia in the Aldrete Post Anesthetic Recovery Score © Modified for Ambulatory Anesthesia field, select the applicable options in the following sections. Activity Dressing Respiration Pain Circulation Ambulation Consciousness Fasting - Feeding O2 Saturation Urine Output Note: The Aldrete Post Anesthetic Score must be at least 18 to discharge a patient. Select the Sign off check box. The username and current date appear in Com

NextGen® Adaptive Content Engine Help Enterprise 8

Document the Pre-Procedure Details for Hysteroscopy, Ablation, or Sterilization

You can document the pre-procedure details of Hysteroscopy, Ablation, or Sterilization in the Pre-Procedure section on the Hysteroscopy - Procedure template. Open the Hysteroscopy - Procedure template. In the Pre-Procedure section, enter the following details: Pre-Procedure section Current contraception LMP If the LMP is entered on the Vital Signs template, LMP appears automatically. Assistant Chaperone Sonographer Transportation Optional: Select the Negative pregnancy test check box. In Pre-op medication, select the applicable medications in Med #1, Med #2, Med #3. To enter the time of medication, do one of the following: To enter the current time, select . To enter the time using the Time Entry template, select the down arrow . Enter the time in Time given. In Pre-Procedure care, select the pre-procedure care details. To enter consent details, select Consent. To enter or view additional screening or sleep apnea assessment documents, select the Configurable Questionnaire links to open

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Manage ASC Vital Signs

You can continuously monitor the vital signs of a patient in the Vital Signs Monitoring panel on the Hysteroscopy - Procedure template. Open the Hysteroscopy - Procedure template. In the Vital Signs Monitoring panel, select Add. The ASC Vital Signs Monitoring template opens. ASC Vital Signs Monitoring template In the Vital Signs Monitoring section, do the following: Select the stage of monitoring. To indicate the vitals are a baseline reading, select the Baseline check box. The vital signs details are added to the Baseline Vital Signs grid. Enter the following details: Time Temp(F) Pulse Resp Sys BP Dias BP SpO2 CO2 (mmHg) ECG rate ECG rhythm Select the pain level and level of consciousness. Enter the details for bleeding severity and blood loss. To show who monitored the vital signs, select the Monitored by check box, and then select a user in the Monitored by field. To show the height and weight details at the top of the vital signs grid in the Vital Signs Monitoring panel, select th

Document the Hysteroscopy, Ablation, or Sterilization Indication for Procedures

Recommendations

Document the Hysteroscopy, Ablation, or Sterilization Findings Details

Document the Hysteroscopy, Ablation, or Sterilization Anesthesia Details

Document the Hysteroscopy, Ablation, or Sterilization Recovery and Discharge Details

Document the Aldrete Score

Document the Pre-Procedure Details for Hysteroscopy, Ablation, or Sterilization

Manage ASC Vital Signs

Document the Hysteroscopy, Ablation, or Sterilization Findings Details

Document the Hysteroscopy, Ablation, or Sterilization Anesthesia Details

Document the Hysteroscopy, Ablation, or Sterilization Recovery and Discharge Details

Document the Aldrete Score

Document the Pre-Procedure Details for Hysteroscopy, Ablation, or Sterilization

Manage ASC Vital Signs