Introduction

This training material is a review on how to document and submit to superbill a foreign body removal procedure.


Topics Covered:

  • Accessing template
  • Pre-Procedure Care
  • Eyes
  • Other 
  • Removal Method
  • Suture
  • Dressing wound care & follow up

Accessing Template


1. Click on the blue text Procedures link to open a template or can access from the procedures icon located at the bottom of the SOAP template. Then select the 'Lesion/Wart/Punch/Other' to open the template.


Note: If opening from the procedures icon at the bottom of SOAP, the template is named 'Foreign body removal.' 



Pre-Procedure Care


1. After opening template, select all that apply regarding consents that were reviewed and given to the patient.


Eyes


1. Check 'Eyelid everted and examined' box if the procedure is performed.

2. Check all that apply. Details button will prompt as selecting checkboxes to enter detail information about findings. 

3. The diagnosis search window will prompt to choose when entering procedure.


Other


1.  Check either of the boxes if procedure(s) were performed on the ear. After selecting a box, the detail selections will prompt for selection. Picklist will also prompt for selection. Select all that apply.

2. PE Ears and PE skin (physical exam) link is available if needing to enter more detail information.

Please refer to 'Physical Exam' training material for more information.


Removal Method


1.  Select what method used for the procedure. Select all that apply.


Anesthetic/Medications

1. If any anesthetic or/and medications were used during procedure select all that apply. From the Anesthetic amount, picklist select the appropriate dosage. If none apply can manually type amount. 


Suture


1. Select all that apply. When entering suture type, the removal timeframe will populate under the follow-up section. 



Dressing, Wound Care & Follow Up


1. Check all that apply. Click in the follow-up box to display picklist to select from. Click in the comment box to display comment picklist to select from. If none apply, Click the close button and free type in the comment box.


After documentation, click the 'Submit to Superbill' button. Will change to red text Charges submitted. Then click 'Save & Close' button. 


Resources

  • Clinical Workflow-SOAP
  • Clinical Workflow-Physical Exam
  • Medication Module