Schedule a Biopsy Encounter on the SOAP Template
On the
Intake - Dermatology
template, select an appropriate reason for visit.
The corresponding HPI template opens.
Complete the HPI template and select
Save & Close
.
On the
SOAP
template, go to the
Physical Exam
panel, and click
Full Skin
.
The
Dermatology Quick Exams - PE
template opens.
Select an entry from the
Today's Quick Exams
grid or add an assessment.
The system populates the template with data for the selected assessment.
In the
Treatment
section, select the
Biopsy
option, and select a method from the Biopsy procedure list.
To select a time frame from the list, select the
Schedule in
option, and select a value from the list.
Select the location where the biopsy needs to be performed in the
Site specific
section.
Make any other necessary entries on the template.
To update the record to the grid select
Update
.
Select
Save & Close
.
On the
SOAP
template, in the
Assessment / Plan
panel, the system adds a record.
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Schedule a Biopsy Encounter with GET
On the Intake - Dermatology template, select an appropriate reason for visit. The corresponding HPI template opens. Complete the HPI template and select Save & Close. Open the GET template, and select an appropriate finding from the Findings list. Click the image at the location that corresponds to the location of the finding. The system places a marker at that location and creates a record on the grid below the image. Click the link in the name column for the record. The Dermatology Quick Exams - PE template opens. Select an entry from the Today's Quick Exams grid or add an assessment. The system populates the template with data for the selected assessment. In the Treatment section, select the Biopsy option, and select a method from the Biopsy procedure list. To select a time frame from the list, select the Schedule in option, and select a value from the list. Select the location where the biopsy needs to be performed in the Site specific section. Make any other necessary entries on t
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Document a Biopsy Procedure
On the SOAP template, go to the bottom of the template and select the Procedures icon. The Udp Procedure Picklist opens. Click Biopsy/Destruction/Shave Removal. The Biopsy/Destruction/Shave - Procedures template opens. In the Pre-Procedure Care panel, after explaining the details of the procedure to the patient select the relevant options. Note: To add more information about the consent, select the Consent link. In the Procedure Care section, select No for Are you performing a procedure on a biopsy proven malignancy?. In the Site Details section, click Procedure and select Biopsy from the resulting list. Select a method. Use the resulting Search window to select the specific condition. Select a Status. Document the Location and Site Specific fields. Click Quantity and select the number of items to be biopsied. Select an Indication. Select the anesthesia being used from the picklist and enter the amount used in milliliters. To add the procedure to the Today's Procedures grid, click Add.
NextGen® Adaptive Content Engine Help Enterprise 8
Biopsy
When you determine that a biopsy is required for a patient, you can perform the following procedure: Scheduling a biopsy test. Performing the procedure to collect the specimen or specimens. Recording the pathology results details. Intake Staff Workflow to Schedule a Biopsy Encounter When the provider determines that a biopsy is required, the intake staff follows the required procedure. Schedule a Biopsy Encounter on the SOAP Template You can schedule a biopsy encounter on the SOAP template. Schedule a Biopsy Encounter with GET You can schedule a biopsy encounter on the GET template. Document a Biopsy Procedure You can document procedure for a patient with a specific complaint on whom you expect to perform a biopsy. Record Biopsy Results You can enter into the application the details of biopsy results that are returned from a lab in a non-electronic form. Parent topic: Predominant Procedures for Provider
NextGen® Adaptive Content Engine Help Enterprise 8
Complete the Derm Quick HPI Template
The Derm Quick HPI template enables you to enter the following patient information: General information about the patient's chief concern Dermatology specific information, including location of concern, skin type, cancer history and date of last exam Current and previous treatments Additional relevant details You can add up to six complaints on the HPI grid. In the Reason for Visit panel of the SOAP template, click derm quick hpi in the left pane. The Derm Quick HPI template opens. In the General panel, click the Concern field and select the patient's chief concern from the resulting list. To enter a duration for the concern, click the Duration field and use the resulting calculator. If this is a follow-up exam for treatment of the chief concern, click the Follow up check box. To select the current status of the concern, click Status. To indicate the date that the patient first noticed the concern, click Lesion noticed. If appropriate, select a Severity for the concern, either Mild, Mo
NextGen® Adaptive Content Engine Help Enterprise 8
Schedule a Blue Light Encounter on the SOAP Template
On the Intake - Dermatology template, select an appropriate reason for visit. The corresponding HPI template opens. Complete the HPI template and select Save & Close. On the SOAP template, go to the Physical Exam panel, and click Full Skin. The Dermatology Quick Exams - PE template opens. Select Quick exam defaults and select Actinic Keratosis from the list. The system populates the template with the currently defined default settings for actinic keratosis. To add a diagnosis, select Assessment and select actinic keratosis. In the Treatment section, do the following: Select Other Treatment and then select Blue Light from the list. Note: If the Blue Light option is not available, then select the blank field at the top of the list and enter Blue Light Therapy. To add the procedure date, select the Schedule in option and select a time frame from the list. Make any other necessary entries on the template. To add the record to the grid, select Add. Select Save & Close. The system adds the r
NextGen® Adaptive Content Engine Help Enterprise 8
Document a Routine Visit
After the intake staff completes their work with the patient, you can document the patient encounter. On Dermatology Home Page template, review the patient information entered by the intake staff. On the Histories template, review the patient information and make the desired modifications. On the SOAP template, view the details of reason for entered by the intake staff in the Reason for Visit panel. You can enter additional reasons for visit. In the Review of Systems panel, to document patient's signs and symptoms, do one of the following: Click the ROS defaults field, and then select an appropriate default ROS from the list. Click DERM - ROS and do one of the following in the Dermatology-ROS template. To select negative or positive for symptoms in a system, select either Neg or Pos options. To mark negative for all symptoms in a specific system, select All neg in the respective system. To document the findings in detail for a specific system, click the respective system link, and then
