Office Procedure Templates Don Stewart PPUG 2009 Don

Office Procedure Templates Don Stewart PPUG 2009 Don. S@SDALC. org

Adding Procedure Notes Procedure Note: «DEL» «*Ellip. Exc» «*Punch. Bx» «*Seb. Punch» «*Lipo. Incis» «*Shave. Bx» «*Vasect 1» «*Nail. Excision» «*Ear. Wash» «*Cryotherapy» «*Joint_Injections. . . » «*Skin. Tag. Removal» «*Excise. Hemorrhoid» «*Foreign. Body. Removal» «*Subungual_Hematoma_Evac» «*Destr_Malig_Lesion»

What Do You Need? • • Informed consent Description of the procedure Follow-up plans Codes

Informed Consent

Description of Elliptical Excision «*Informed_Consent_Bx» Using «*2» «*1» % Lidocaine with «*out» Epi local anesthesia and «*Alcohol» «*Betadine» prep, after the lesion had been appropriately draped, an elliptical full-thickeness excision was done. The lesion was placed in formalin and sent to Pathology. Bleeding was controlled with pressure and cautery. After appropriate undermining, the wound was closed with interrupted «*4» «*5» «*6» -0 «*Proline» «*Ethilon» and bandaged appropriately. Patient was instructed to return for suture removal in «*3» «*-» «*5» «*-» «*7» «*-» «*10» «*-» «*14» days. «*Excis_Malig. Les. . . » «*Excise_Benign. Les. . . »

*Excise Benign Les Pick list

The Procedure Code

Lesion Size Pick List

Now for the Diagnosis Code

Derm Diagnoses

Before Saving the Note

After Saving the Note