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Appearance and Quantity of Fluid Drawn
Appearance and Quantity of Fluid Drawn
You can document the appearance and quantity of fluid drawn. You can also specify if the fluid is being sent for cell, crystals, or cultures.
Note:
This is for documentation only; it does not place an order for cells, crystals, or cultures.
Complete the procedure information manually or by using a QuickPick.
Select the
Appearance
field.
The
MLTS Dbpl Asp Appear
picklist opens. This is a multipick list, so it remains open for you to keep selecting values until you close it.
Do one or both of the following:
Select the Free Text option and click
OK
, to enter an appearance not in the picklist.
Select an appearance from the picklist and click
OK
to add it to the field.
Repeat step 3 to select as many descriptors for fluid appearance as needed.
Select--
Done
and click
OK
to close the appearance picklist.
The values are entered in the
Appearance
field.
Select the
Quantity
field and use the number pad to enter the quantity in cc’s of fluid drawn off.
Mark the Cell, Crystal, or Culture check boxes as appropriate to document if the fluid will be sent for testing. This does not place the order.
NextGen® Medication Inventory Control Help 10.6.3.0
Document Aspiration Procedure Information
You can manually document aspiration procedure in the Procedure Type panel on the MICS Injections/Aspirations template. You can manually document the aspiration procedure in the following fields or using a Quickpick. On the MICS Injections/Aspirations template, expand the Procedure Type panel. Select the Procedure Type as Aspiration. In the Admin Type field, select administration type. The Body Parts picklist opens. Select the body part from the picklist, and select OK. The Sides picklist opens. Select the side from the picklist, and select OK. The Locations picklist opens. Select the location from the picklist, and select OK. The Portal/Approach picklist opens. Select the portal and approach from the picklist, and select OK. All the fields display the values you selected. The CPT code field is filled based on the Admin Type selected. The Modifier field is filled based on the Side selected. To associate a diagnosis code with the procedure, select a diagnosis in the Diagnosis field. Not
NextGen® Medication Inventory Control Help 10.6.3.0
Additional Procedure Information
If needle placement is confirmed using one of the above listed techniques the Medical Necessity field becomes required. The Technique, Anesthetic, Needle Gauge and Sterile Dressing fields are all optional. Selecting an item in one the of fields automatically opens the picklist for the field that follows. To conclude documentation at any point, click Cancel in the picklist, or close the picklist. Select the Medical Necessity field and select the item from the picklist. The MLTSTechniquePL picklist opens. Select a technique from the picklist and click OK. The MLTSanestheticPL picklist opens. Select an anesthetic from the picklist and click OK. The system runs a DUR Check for the medication and the MLTSneedleGaugePL picklist opens. Select the needle gauge from the picklist and click OK. The MLTS SterileDressPL picklist opens. Select the sterile dressing from the picklist and click OK. All the procedure information is now filled in. You can use the Procedure Notes field below the panel to
NextGen® Medication Inventory Control Help 10.6.3.0
Documenting an Aspiration
You can document the general procedure details, appearance, and quantity of the fluid drawn off, and the patient’s response for an aspiration procedure in the Procedure Type panel on the MICS Injections/Aspirations template. You can manually document the aspiration procedure information or use QuickPicks. Document Aspiration Procedure Information You can manually document aspiration procedure in the Procedure Type panel on the MICS Injections/Aspirations template. Document Needle Placement Confirmation and Medical Necessity Additional Procedure Information Appearance and Quantity of Fluid Drawn Parent topic: Documenting Injections and Aspirations Related tasks Document Using QuickPicks
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Document an Aspiration or Injection Procedure
In the Joint Aspiration/Injection template, highlight the diagnosis in the grid under Today’s Assessments. In the Procedure field, click to select a value from list. Select a Location from the picklists that display for the chosen procedure. To enter the method used, do one of the following: Click the Method field to select a value from the resulting list. Click the top, blank row in the picklist to free text an entry in the Method field. Joint Aspiration/Injection template If a specific site was prepped, in the Site Prepped section, select Yes. To choose a value for how the site was prepped, do one of the following: Click the Technique field. Click the blank row in the picklist to free text an entry. To specify the anesthetic provided for this patient, do one of the following: In the Anesthetic field, click to select a value from the picklist. Click the top row to free text the anesthetic. Click the mL field to enter a unit value. To specify the gauge of the needle, do one of the foll
NextGen® Orthopedic Suite Help 80.2.14.0
Document Incisions and Drainage Procedures
You can document the Incisions and Drainage (I&D) procedures performed in office. Open the IORTS Castsplint Apply template. Click I & D in the left pane. The IORTSproc Ind template opens. IORTS Incisions and Drainage template Select the appropriate I&D procedure type. If you select Ndle Asp of Fluid Coll (needle aspiration) or I and D of Fluid Coll (incision and drainage), the list automatically opens for the following fields. You can select the options from the lists. Type of Fluid Side Location Instrument used If you select I and D of Abscess (abscess incision and drainage), the list automatically opens for the following fields. You can select the options from the lists. Side Location Instrument used Enter the anesthetic injection dosage as follows: Click the Lido w/o field, and select the injection dosage for Lidocaine without epinephrine. Click the Lido /Epi field, and select the injection dosage for Lidocaine with epinephrine. Click the Marc field, and select the injection dosage
NextGen® Medication Inventory Control Help 10.6.3.0
Build the Medication Quantity Picklist
You must add in all quantities of every medication that you expect to use. Select the field below the Medication column of the grid. The MLTS MedOnly PL picklist opens. Select the medication from the list and select OK. Note: Your selection in the Medication field also serves as a filter for the grid, so that you can see all entries for that medication. The medication enters the field and the read-only UnitType field fills in also. Select the field below the Quantity column. A Number Pad window opens. Enter the number and select OK. Select Add. The quantity is added to the grid. The medication and the unit type remain in the fields below the grid so that you can add other quantities for the same medication. Repeat steps 3-5 as needed to add other quantities for the selected medication. When finished adding quantities for that medication, repeat steps 1-6 to add other quantities for other medications. Note: To clear the fields, select the Eraser button to the right of the fields. Parent
