On the Urethral Dilation - Procedure template, you can document the details of the urethral dilation procedure including pre-procedure care, procedure findings, and post procedure details.
- On the SOAP template, select the Procedures link.
The Procedures template opens.
- In the Genitourinary section, click Urethral Dilation .
The
Urethral Dilation - Procedure 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.
The gender is automatically filled.
- 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.
- Select the episode.
- In the Procedure section, do the following:
- Specify the urethral stricture location and size.
- Select Patient prepped and draped in the usual sterile fashion.
- Select the method by which urethral dilation is performed.
- Enter the anesthesia details.
- To enter other procedure details, click Other Procedure and Code.
- Enter the post-procedure and follow-up details.
- Enter any additional information in Comments.
- To submit the procedure charges, click Submit to Superbill.
- Click Save & Close.
