Procedure Note
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[select memo="select procedure" name="ProcType" value="|IUD INSERTION|IUD REMOVAL|IUD REMOVAL/REINSERTION|NEXPLANON INSERTION|NEXPLANON REMOVAL|NEXPLANON REMOVAL/REINSERTION"]

[conditional field="ProcType" condition="(ProcType).is('IUD INSERTION')"]PRE-OP DIAGNOSIS: [checkbox value="Z30.430 Encounter for insertion of IUD|Z30.014 Encounter for initial prescription of IUD"]
POST-OP DIAGNOSIS: [checkbox value="Z30.430 Encounter for insertion of IUD|Z30.014 Encounter for initial prescription of IUD"][comment memo="Z30.014 includes the initial prescription of the IUD, counseling, and advice, but excludes the IUD insertion" memo_size="small"]

PROCEDURE: Insertion of IUD - CPT 58300
IUD LOT#: [text size="20"]
[checkbox name="IUDInsSup" value="Supervising Physician:"][/conditional][conditional field="IUDInsSup" condition="(IUDInsSup).is('Supervising Physician:')"] Dr. [text size="20"]
[/conditional][conditional field="ProcType" condition="(ProcType).is('IUD INSERTION')"]
INDICATIONS/COUNSELING:
-Patient desires long-term, reversible contraception.
-Reason(s) patient desires this specific IUD: [checkbox value="prevent pregnancy|irregular menses|dysmenorrhea|menorrhagia|dysfunctional uterine bleeding|forgets to take pills|other-"] [text size="50"]
-The patient was counseled regarding the risks, benefits and alternatives of IUD insertion and use.
-She is aware that there are other methods of contraception such as OCPs, contraceptive patches and rings and barrier methods of contraception.
-She was informed that the failure rate is about one woman for every 1000 women who use the IUD for one year.
-If she should become pregnant, the risk of ectopic or tubal pregnancy is about 50%.
-If she ever has symptoms of pregnancy, she should have a pregnancy test immediately as tubal pregnancies can be life threatening.
-Complications following insertion of an IUD are rare.
-There is a small possibility that the instrument used to measure the uterus or the IUD itself could perforate the wall of the uterus. This might not be obvious immediately.
-If she experiences symptoms of infection such as pain, fever >100.4, chills, painful intercourse, nausea and vomiting, prolonged bleeding or foul smelling discharge, she should be seen in clinic.
-In the rare event that an IUD has passed through the wall of the uterus into the abdomen, it will need to be removed surgically. In extreme cases, the IUD may cause scarring which could lead to the need for a hysterectomy (surgery to remove the uterus) and the inability to have children.
-She was advised to check her string after each menstrual cycle or at least monthly and to make an appointment with her provider immediately if she is not able to find the strings, suspects she is pregnant or experiences any of the symptoms mentioned above.
-Confirmed that all of her questions were answered and she desires to proceed with the IUD insertion.
-Verified that the consent form was signed.
-A time out was performed prior to the procedure and documented in a hardcopy form to be scanned into patient's record.

PROCEDURE:
[checkbox name="bimanual" value="-Bimanual exam was performed and position of uterus determined to be "][conditional field="bimanual" condition="(bimanual).is('-Bimanual exam was performed and position of uterus determined to be ')"][select value="anteroverted.|midposition.|posteroverted."]
[/conditional][conditional field="ProcType" condition="(ProcType).is('IUD INSERTION')"]-The speculum was inserted and the cervix was identified.
-[select value="|Betadine|Chlorhexidine"] was used to clean the cervix.
[checkbox value="-An os dilator was used.
"][checkbox value="-A sound was used.
"]-Uterus sounded to a depth of [text size="5"] cm.
-[select memo="choose whether tenaculum used" memo_size="small" name="tenaculum1" value="|A tenaculum was applied to |A tenaculum was not used. "][/conditional][conditional field="tenaculum1" condition="(tenaculum1).is('A tenaculum was applied to ')"][select value="superior/anterior cervix. |posterior/inferior cervix."][/conditional][conditional field="ProcType" condition="(ProcType).is('IUD INSERTION')"]
-[select value="Mirena|Kyleena|Skyla|Paragard/Copper IUD"] was inserted per manufacturer protocol.
-The string was cut to a 3 centimeters length and a sample of the remaining string was given to the patient for later comparison.
[checkbox value="-EBL less than 5 ml.
"][checkbox value="-The patient tolerated the procedure well, without any S/S of vasovagal responses or other immediate procedural complications.
"][checkbox value="-Gave return precautions: fever, severe lower abdominal cramping, heavy bleeding, or purulent discharge.
"][checkbox value="-The patient was counseled to check the strings herself monthly to ensure the IUD has not been displaced.
"][checkbox memo="check for free text" memo_size="small" name="IUDfreetext" value=""][/conditional][conditional field="IUDfreetext" condition="(IUDfreetext).is('')"][textarea]
[/conditional][conditional field="ProcType" condition="(ProcType).is('IUD REMOVAL')"]PRE-OP DIAGNOSIS: Z30.432 Encounter for removal of IUD
POST-OP DIAGNOSIS: Z30.432 Encounter for removal of IUD

PROCEDURE: Removal of IUD - CPT 58301
[checkbox name="IUDRemovSup" value="Supervising Physician:"][/conditional][conditional field="IUDRemovSup" condition="(IUDRemovSup).is('Supervising Physician:')"] Dr. [text size="20"]
[/conditional][conditional field="ProcType" condition="(ProcType).is('IUD REMOVAL')"]
INDICATIONS/COUNSELING:
-Confirmed patient desires removal of IUD for the following reason: [select value="|desires to get pregnant|current IUD needs replaced|having undesirable side effects"].
-Confirmed patient aware of ability to get pregnant once removed if this IUD form of contraception not replaced or appropriately transitioned to another form of contraception.
-Confirmed that patient has plan in place for alternate form of contraception if not desiring to get pregnant
-Verified that the consent form was signed.
-A time out was performed prior to the procedure and documented in a hardcopy form to be scanned into patient's record.

PROCEDURE:
-The speculum was inserted and the cervix was identified.
-The IUD strings were: [select name="IUDstrings1" value="|identified|not identified"][/conditional][conditional field="IUDstrings1" condition="(IUDstrings1).is('identified')"] and grasped with a Kelly clamp.
-With gentle traction, the IUD was [select name="IUDtraction1" value="|removed.|unable to be removed."][/conditional][conditional field="IUDtraction1" condition="(IUDtraction1).is('unable to be removed.')"]
-The following actions were taken: [checkbox value="Patient referred to Gynecologist for assistance with extraction|Pelvic ultrasound was ordered to confirm location of IUD|other-"][textarea memo="add'l actions taken" memo_size="small" memo_color="orange"][/conditional][conditional field="IUDstrings1" condition="(IUDstrings1).is('not identified')"].
-Attempted retrieval of strings with cytobrush and [select name="cytobrushretrieval1" value="|successful.|unsuccessful."][/conditional][conditional field="cytobrushretrieval1" condition="(cytobrushretrieval1).is('successful.')"]
-Strings were grasped with a Kelly clamp.
-With gentle traction, the IUD was [select name="IUDtraction2" value="|removed.|unable to be removed."][/conditional][conditional field="IUDtraction2" condition="(IUDtraction2).is('unable to be removed.')"]
-The following actions were taken: [checkbox value="Patient referred to Gynecologist for assistance with extraction|Pelvic ultrasound was ordered to confirm location of IUD|other-"][textarea memo="add'l actions taken" memo_size="small" memo_color="orange"][/conditional][conditional field="cytobrushretrieval1" condition="(cytobrushretrieval1).is('unsuccessful.')"]
-The following actions were taken: [checkbox value="Patient referred to Gynecologist for assistance with extraction|Pelvic ultrasound was ordered to confirm location of IUD|other-"][textarea memo="add'l actions taken" memo_size="small" memo_color="orange"][/conditional][conditional field="ProcType" condition="(ProcType).is('IUD REMOVAL/REINSERTION')"]

PRE-OP DIAGNOSIS: Z30.433 Encounter for removal and reinsertion of intrauterine
contraceptive device
POST-OP DIAGNOSIS: Z30.433 Encounter for removal and reinsertion of intrauterine
contraceptive device

PROCEDURE: Removal of IUD - CPT 58301 & Insertion of IUD - CPT 58300
IUD LOT#: [text size="20"]
[checkbox name="IUDRemovReinsSup" value="Supervising Physician:"][/conditional][conditional field="IUDRemovReinsSup" condition="(IUDRemovReinsSup).is('Supervising Physician:')"] Dr. [text size="20"]
[/conditional][conditional field="ProcType" condition="(ProcType).is('IUD REMOVAL/REINSERTION')"]
INDICATIONS/COUNSELING:
-Confirmed patient desires removal of IUD due to current IUD needing replacement and patient continues to desire long-term contraception.
-Reason(s) patient desires to continue this specific IUD: [checkbox value="prevent pregnancy|irregular menses|dysmenorrhea|menorrhagia|dysfunctional uterine bleeding|forgets to take pills|other-"] [text size="50"]
-The patient was counseled regarding the risks, benefits and alternatives of IUD insertion and use.
-She is aware that there are other methods of contraception such as OCPs, contraceptive patches and rings and barrier methods of contraception.
-She was informed that the failure rate is about one woman for every 1000 women who use the IUD for one year.
-If she should become pregnant, the risk of ectopic or tubal pregnancy is about 50%.
-If she ever has symptoms of pregnancy, she should have a pregnancy test immediately as tubal pregnancies can be life threatening.
-Complications following insertion of an IUD are rare.
-There is a small possibility that the instrument used to measure the uterus or the IUD itself could perforate the wall of the uterus. This might not be obvious immediately.
-If she experiences symptoms of infection such as pain, fever >100.4, chills, painful intercourse, nausea and vomiting, prolonged bleeding or foul smelling discharge, she should be seen in clinic.
-In the rare event that an IUD has passed through the wall of the uterus into the abdomen, it will need to be removed surgically. In extreme cases, the IUD may cause scarring which could lead to the need for a hysterectomy (surgery to remove the uterus) and the inability to have children.
-She was advised to check her string after each menstrual cycle or at least monthly and to make an appointment with her provider immediately if she is not able to find the strings, suspects she is pregnant or experiences any of the symptoms mentioned above.
-Confirmed that all of her questions were answered and she desires to proceed with the IUD reinsertion.
-Verified that the consent form was signed.
-A time out was performed prior to the procedure and documented in a hardcopy form to be scanned into patient's record.

PROCEDURE:
-The speculum was inserted and the cervix was identified.
-The IUD strings were: [select name="IUDstrings2" value="|identified|not identified"][/conditional][conditional field="IUDstrings2" condition="(IUDstrings2).is('identified')"] and grasped with a Kelly clamp.
-With gentle traction, the IUD was [select name="IUDtraction3" value="|removed.|unable to be removed."][/conditional][conditional field="IUDtraction3" condition="(IUDtraction3).is('unable to be removed.')"]
-The following actions were taken: [checkbox value="Patient referred to Gynecologist for assistance with extraction|Pelvic ultrasound was ordered to confirm location of IUD|other-"][textarea memo="add'l actions taken" memo_size="small" memo_color="orange"][/conditional][conditional field="IUDstrings2" condition="(IUDstrings2).is('not identified')"].
-Attempted retrieval of strings with cytobrush and [select name="cytobrushretrieval2" value="|successful.|unsuccessful."][/conditional][conditional field="cytobrushretrieval2" condition="(cytobrushretrieval2).is('successful.')"]
-Strings were grasped with a Kelly clamp.
-With gentle traction, the IUD was [select name="IUDtraction4" value="|removed.|unable to be removed."][/conditional][conditional field="IUDtraction4" condition="(IUDtraction4).is('unable to be removed.')"]
-The following actions were taken: [checkbox value="Patient referred to Gynecologist for assistance with extraction|Pelvic ultrasound was ordered to confirm location of IUD|other-"][textarea memo="add'l actions taken" memo_size="small" memo_color="orange"][/conditional][conditional field="cytobrushretrieval2" condition="(cytobrushretrieval2).is('unsuccessful.')"]
-The following actions were taken: [checkbox value="Patient referred to Gynecologist for assistance with extraction|Pelvic ultrasound was ordered to confirm location of IUD|other-"][textarea memo="add'l actions taken" memo_size="small" memo_color="orange"][/conditional][conditional field="ProcType" condition="(ProcType).is('IUD REMOVAL/REINSERTION')"]
[checkbox memo="check if removal successful" name="removalsuccess" value=""][/conditional][conditional field="removalsuccess" condition="(removalsuccess).is('')"]-[select value="|Betadine|Chlorhexidine"] was used to clean the cervix.
[checkbox value="-An os dilator was used.
"][checkbox value="-A sound was used.
"]-Uterus sounded to a depth of [text size="5"] cm.
-[select memo="choose whether tenaculum used" memo_size="small" name="tenaculum2" value="|A tenaculum was applied to |A tenaculum was not used. "][/conditional][conditional field="tenaculum2" condition="(tenaculum2).is('A tenaculum was applied to ')"][select value="superior/anterior cervix. |posterior/inferior cervix."][/conditional][conditional field="removalsuccess" condition="(removalsuccess).is('')"]
-[select value="Mirena|Kyleena|Skyla|Paragard/Copper IUD"] was inserted per manufacturer protocol.
-The string was cut to a 3 centimeters length and a sample of the remaining string was given to the patient for later comparison.
[checkbox value="-EBL less than 5 ml.
"][checkbox value="-The patient tolerated the procedure well, without any S/S of vasovagal responses or other immediate procedural complications.
"][checkbox value="-Gave return precautions: fever, severe lower abdominal cramping, heavy bleeding, or purulent discharge.
"][checkbox value="-The patient was counseled to check the strings herself monthly to ensure the IUD has not been displaced.
"][checkbox memo="check for free text" memo_size="small" name="IUDfreetext" value=""][/conditional][conditional field="IUDfreetext" condition="(IUDfreetext).is('')"][textarea]
[/conditional][conditional field="ProcType" condition="(ProcType).is('NEXPLANON INSERTION')"]

PRE-OP DIAGNOSIS: Z30.017 Encounter for initial prescription of implantable
subdermal contraceptive
POST-OP DIAGNOSIS: Z30.017 Encounter for initial prescription of implantable
subdermal contraceptive

PROCEDURE: Insertion of Nexplanon - CPT 11981
NEXPLANON LOT#: [text size="20"]
[checkbox name="NexpInsSup" value="Supervising Physician:"][/conditional][conditional field="NexpInsSup" condition="(NexpInsSup).is('Supervising Physician:')"] Dr. [text size="20"]
[/conditional][conditional field="ProcType" condition="(ProcType).is('NEXPLANON INSERTION')"]
COUNSELING/INDICATIONS:
-Reason(s) patient desires this specific form of contraception: [checkbox value="prevent pregnancy|irregular menses|dysmenorrhea|menorrhagia|dysfunctional uterine bleeding|forgets to take pills|other-"] [text size="50"]
-The patient was counseled regarding the risks, benefits and alternatives of Nexplanon insertion and use.
-She is aware that there are other methods of contraception such as OCPs, contraceptive patches and rings and barrier methods of contraception.
-Discussed and patient verbalized understanding of the risks, benefits, alternatives and possible complications of subdermal implants to include:
--possible contraindications include known or suspected pregnancy, current or past history of thrombosis, liver disease, undiagnosed abnormal genital bleeding, current or past history of breast cancer, allergic reaction to any components of the Nexplanon device.
--potential changes in menstrual bleeding pattern including 22% amenorrhea, 18% prolonged bleeding, 7% frequent bleeding, 34% infrequent bleeding.
--possible adverse effects including ectopic pregnancy, thrombotic events or liver disease, depression or emotional lability, headache, weight increase.
--Nexplanon may be used for nursing after the 4th week.
-Confirmed that all of her questions were answered and she desires to proceed with the Nexplanon insertion.
-Verified that the consent form was signed.
-A time out was performed prior to the procedure and documented in a hardcopy form to be scanned into patient's record.

PROCEDURE:
-[select value="Left|Right"] arm landmarks identified and insertion site and guiding site marked with [select value="tissue marker|retracted tip of pen"] per manufacturer's recommendations.
-Area cleansed with [select value="Betadine/Iodine|Chlorhexidine"] and adequate drying time allowed per manufacturer recommendations and infection control protocol.
-[text size="5"]ml of [select value="2%|1%"] lidocaine with epinephrine was injected with 27g needle under the skin of the identified insertion point and along the insertion canal.
-In sterile fashion applicator was inspected and presence of Nexplanon device verified.
-Applicator used to insert Nexplanon device.
-Grooved tip of obturator was visible inside needle upon removal.
-Both myself and patient palpated the Nexplanon device in subdermal location.
-Hemostasis assured.
-EBL < 1ml.
-The site was dressed with [checkbox value="Dermabond|SteriStrips|pressure dressing|bacitracin ointment"].
-Wound care instructions reviewed.
-Discussed return precautions to include: [checkbox value="bleeding at insertion site that is continuing to soak through pads after first removed|worsening pain after first 24 hours|increasing swelling after first 24 hours|pus coming from insertion site|fever"].
[/conditional][conditional field="ProcType" condition="(ProcType).is('NEXPLANON REMOVAL')"]

PRE-OP DIAGNOSIS: Z30.46 Encounter for surveillance of implantable subdermal
contraceptive
POST-OP DIAGNOSIS: Z30.46 Encounter for surveillance of implantable subdermal
contraceptive

PROCEDURE: Removal of nexplanon - CPT 11982
[checkbox name="NexpRemovSup" value="Supervising Physician:"][/conditional][conditional field="NexpRemovSup" condition="(NexpRemovSup).is('Supervising Physician:')"] Dr. [text size="20"]
[/conditional][conditional field="ProcType" condition="(ProcType).is('NEXPLANON REMOVAL')"]
INDICATIONS/COUNSELING:
-Confirmed patient desires removal of Nexplanon for the following reason: [select value="|desires to get pregnant|having undesirable side effects"]. [text memo="add'l explanation if needed" memo_size="small" size="50"]
-Confirmed patient aware of ability to get pregnant once removed if this Nexplanon device not replaced or appropriately transitioned to another form of contraception.
-Confirmed that patient has plan in place for alternate form of contraception if not desiring to get pregnant
-Verified that the consent form was signed.
-A time out was performed prior to the procedure and documented in a hardcopy form to be scanned into patient's record.

PROCEDURE
-Device was palpated, distal end identified, and guiding site marked with [select value="tissue marker|retracted tip of pen"]
-The area surrounding the Nexplanon was cleansed with [select value="Betadine/Iodine|Chlorhexidine"] and adequate drying time allowed per manufacturer recommendations and infection control protocol.
-[text size="5"]ml of [select value="2%|1%"] lidocaine with epinephrine was injected with 27g needle through the skin enough to form a very small wheal and the remainder under the distal aspect of the device.
-Using [select value="#11blade|#15blade"] scalpel, a skin incision was made over the distal aspect of the device.
-The tissue capsule surrounding the device was lysed sharply and the device removed using a hemostat.
-Hemostasis was assured.
-EBL < 1ml.
-The site was dressed with [checkbox value="Dermabond|SteriStrips|pressure dressing|bacitracin ointment"].
-Wound care instructions reviewed.
-Discussed return precautions to include: [checkbox value="bleeding at removal site that is continuing to soak through pads after first removed|worsening pain after first 24 hours|increasing swelling after first 24 hours|pus coming from insertion site|fever"].[/conditional][conditional field="ProcType" condition="(ProcType).is('NEXPLANON REMOVAL/REINSERTION')"]

PRE-OP DIAGNOSIS: Z30.46 Encounter for surveillance of implantable subdermal
contraceptive
POST-OP DIAGNOSIS: Z30.46 Encounter for surveillance of implantable subdermal
contraceptive

PROCEDURE: Removal with reinsertion of nexplanon - CPT 11983
NEXPLANON LOT#: [text size="20"]
[checkbox name="NexpReinsSup" value="Supervising Physician:"][/conditional][conditional field="NexpReinsSup" condition="(NexpReinsSup).is('Supervising Physician:')"] Dr. [text size="20"]
[/conditional][conditional field="ProcType" condition="(ProcType).is('NEXPLANON REMOVAL/REINSERTION')"]
INDICATIONS/COUNSELING:
-Confirmed patient desires removal/reinsertion of Nexplanon for the following reason(s): [select value="current Nexplanon needs replaced|other"]. [text memo="add'l explanation if needed" memo_size="small" size="50"]
-Reason(s) patient desires to continue this specific form of contraception: [checkbox value="prevent pregnancy|irregular menses|dysmenorrhea|menorrhagia|dysfunctional uterine bleeding|forgets to take pills|other-"] [text size="50"]
-The patient was counseled regarding the risks, benefits and alternatives of Nexplanon insertion and use.
-She is aware that there are other methods of contraception such as OCPs, contraceptive patches and rings and barrier methods of contraception.
-Discussed and patient verbalized understanding of the risks, benefits, alternatives and possible complications of subdermal implants to include:
--possible contraindications include known or suspected pregnancy, current or past history of thrombosis, liver disease, undiagnosed abnormal genital bleeding, current or past history of breast cancer, allergic reaction to any components of the Nexplanon device.
--potential changes in menstrual bleeding pattern including 22% amenorrhea, 18% prolonged bleeding, 7% frequent bleeding, 34% infrequent bleeding.
--possible adverse effects including ectopic pregnancy, thrombotic events or liver disease, depression or emotional lability, headache, weight increase.
--Nexplanon may be used for nursing after the 4th week.
-Confirmed that all of her questions were answered and she desires to proceed with the Nexplanon reinsertion.
-Verified that the consent form was signed.
-A time out was performed prior to the procedure and documented in a hardcopy form to be scanned into patient's record.

PROCEDURE:
-Device was palpated, distal end identified, and guiding site marked with [select value="tissue marker|retracted tip of pen"]
-The area surrounding the Nexplanon was cleansed with [select value="Betadine/Iodine|Chlorhexidine"] and adequate drying time allowed per manufacturer recommendations and infection control protocol.
-[text size="5"]ml of [select value="2%|1%"] lidocaine with epinephrine was injected with 27g needle through the skin enough to form a very small wheal and the remainder under the distal aspect of the device.
-Using [select value="#11blade|#15blade"] scalpel, a skin incision was made over the distal aspect of the device.
-The tissue capsule surrounding the device was lysed sharply and the device removed using a hemostat.
-In sterile fashion applicator for replacement Nexplanon device was inspected and presence of Nexplanon device verified.
-Applicator used to insert Nexplanon device [select value="through original/initial incision|through new site that was marked"] on [select "left arm|right arm"] per manufacturers recommendations.
-Grooved tip of obturator was visible inside needle upon removal.
-Both myself and patient palpated the Nexplanon device in subdermal location.
-Hemostasis assured.
-EBL < 1ml.
-The site was dressed with [checkbox value="Dermabond|SteriStrips|pressure dressing|bacitracin ointment"].
-Wound care instructions reviewed.
-Discussed return precautions to include: [checkbox value="bleeding at insertion site that is continuing to soak through pads after first removed|worsening pain after first 24 hours|increasing swelling after first 24 hours|pus coming from insertion site|fever"].
[/conditional]

[checkbox name="PtDisp" value="PATIENT DISPOSITION"][conditional field="PtDisp" condition="(PtDisp).is('PATIENT DISPOSITION')"]
-Patient tolerated overall procedure(s) well
-No immediate complications noted
-Patient left in stable condition with appropriate counseling as described above.[/conditional][checkbox memo="select for additional free text" name="endfreetext" value=""][conditional field="endfreetext" condition="(endfreetext).is('')"]-[textarea memo="additional text"][/conditional] [comment memo="consider adding contraception switch calculator here/TBD"]
select procedure



select for additional free text consider adding contraception switch calculator here/TBD
Result - Copy and paste this output: