Procedure Note
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[checkbox name="femaleprocchap" memo="Chaperone" value=""][conditional field="femaleprocchap" condition="(femaleprocchap).is('')"]CHAPERONE: [select name="femaleprocchap1" value="declined by patient|Shaheda Fields|Adriana Avalos|Tenia Wilson|Stephanie Field|Kirsten Huggins|Seleta McCoy|Crissy Lombardo|Jennifer Colon|Sharon Bryant|Sherri Sharpe|Diane McCray|Alberto Botello|Kimberly Bracey|Mariah Doss|Monique Noriega|"][/conditional][conditional field="femaleprocchap1" condition="(femaleprocchap1).is('')"][text size="60"][/conditional][conditional field="femaleprocchap" condition="(femaleprocchap).is('')"]

[/conditional][select memo="select procedure" name="ProcType" value="|IUD INSERTION|IUD REMOVAL|IUD REMOVAL/REINSERTION|NEXPLANON INSERTION|NEXPLANON REMOVAL|NEXPLANON REMOVAL/REINSERTION|COLPOSCOPY|ENDOMETRIAL BIOPSY"]
[conditional field="ProcType" condition="(ProcType).is('IUD INSERTION')"]
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 to include ensuring: [comment memo="only select what's applicable" memo_size="small"]
[checkbox value="--Patient was identified using full name and DOB.
"][checkbox value="--Patient was evaluated and medical record reviewed including history and lab/imaging findings if applicable.
"][checkbox value="--Procedure and site/side matches the consent form.
"][checkbox value="--Patient was involved in the site/side marking.
"][checkbox name="timeoutIUDins" value="--For final timeout, physician paused or verbally confirmed with procedure team of:"][/conditional][conditional field="timeoutIUDins" condition="(timeoutIUDins).is('--For final timeout, physician paused or verbally confirmed with procedure team of:')"]
[textarea cols="100" rows="3"]---correct patient, correct procedure, and correct site/side.
---The patient has been positioned correctly for the procedure.
---All necessary equipment are available.[/textarea]
[/conditional][conditional field="ProcType" condition="(ProcType).is('IUD INSERTION')"][checkbox value="--Instrument sterility verified.
"]
PROCEDURE:
[checkbox name="bimanual" value="-Bimanual exam was performed and position of uterus determined to be "][/conditional][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')"]
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 to include ensuring: [comment memo="only select what's applicable" memo_size="small"]
[checkbox value="--Patient was identified using full name and DOB.
"][checkbox value="--Patient was evaluated and medical record reviewed including history and lab/imaging findings if applicable.
"][checkbox value="--Procedure and site/side matches the consent form.
"][checkbox value="--Patient was involved in the site/side marking.
"][checkbox name="timeoutIUDremov" value="--For final timeout, physician paused or verbally confirmed with procedure team of:"][/conditional][conditional field="timeoutIUDremov" condition="(timeoutIUDremov).is('--For final timeout, physician paused or verbally confirmed with procedure team of:')"]
[textarea cols="100" rows="3"]---correct patient, correct procedure, and correct site/side.
---The patient has been positioned correctly for the procedure.
---All necessary equipment are available.[/textarea]
[/conditional][conditional field="ProcType" condition="(ProcType).is('IUD REMOVAL')"][checkbox value="--Instrument sterility verified.
"]
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')"]
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 to include ensuring: [comment memo="only select what's applicable" memo_size="small"]
[checkbox value="--Patient was identified using full name and DOB.
"][checkbox value="--Patient was evaluated and medical record reviewed including history and lab/imaging findings if applicable.
"][checkbox value="--Procedure and site/side matches the consent form.
"][checkbox value="--Patient was involved in the site/side marking.
"][checkbox name="timeoutIUDreins" value="--For final timeout, physician paused or verbally confirmed with procedure team of:"][/conditional][conditional field="timeoutIUDreins" condition="(timeoutIUDreins).is('--For final timeout, physician paused or verbally confirmed with procedure team of:')"]
[textarea cols="100" rows="3"]---correct patient, correct procedure, and correct site/side.
---The patient has been positioned correctly for the procedure.
---All necessary equipment are available.[/textarea]
[/conditional][conditional field="ProcType" condition="(ProcType).is('IUD REMOVAL/REINSERTION')"][checkbox value="--Instrument sterility verified.
"]
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')"]
DIAGNOSIS: Z30.017 Encounter for initial prescription of implantable
subdermal contraceptive

PROCEDURE: Insertion of Nexplanon - CPT 11981
NEXPLANON LOT#: [text size="20"]
ANESTHESIA AGENT(S): [checkbox value="Lidocaine 1% with epinephrine|Lidocaine 1% without epinephrine|Lidocaine 2% with epinephrine|Lidocaine 2% without epinephrine|Marcaine 0.5%|Bicarbonate buffering solution"]
-Total amt used: [text size="5"] ml
[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 to include ensuring: [comment memo="only select what's applicable" memo_size="small"]
[checkbox value="--Patient was identified using full name and DOB.
"][checkbox value="--Patient was evaluated and medical record reviewed including history and lab/imaging findings if applicable.
"][checkbox value="--Procedure and site/side matches the consent form.
"][checkbox value="--Patient was involved in the site/side marking.
"][checkbox name="timeoutnexplanonins" value="--For final timeout, physician paused or verbally confirmed with procedure team of:"][/conditional][conditional field="timeoutnexplanonins" condition="(timeoutnexplanonins).is('--For final timeout, physician paused or verbally confirmed with procedure team of:')"]
[textarea cols="100" rows="3"]---correct patient, correct procedure, and correct site/side.
---The patient has been positioned correctly for the procedure.
---All necessary equipment are available.[/textarea]
[/conditional][conditional field="ProcType" condition="(ProcType).is('NEXPLANON INSERTION')"][checkbox value="--Instrument sterility verified.
"]
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.
-Above anesthetic agent 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')"]
DIAGNOSIS: Z30.46 Encounter for surveillance of implantable subdermal
contraceptive

PROCEDURE: Removal of nexplanon - CPT 11982
ANESTHESIA AGENT(S): [checkbox value="Lidocaine 1% with epinephrine|Lidocaine 1% without epinephrine|Lidocaine 2% with epinephrine|Lidocaine 2% without epinephrine|Marcaine 0.5%|Bicarbonate buffering solution"]
-Total amt used: [text size="5"] ml
[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 to include ensuring: [comment memo="only select what's applicable" memo_size="small"]
[checkbox value="--Patient was identified using full name and DOB.
"][checkbox value="--Patient was evaluated and medical record reviewed including history and lab/imaging findings if applicable.
"][checkbox value="--Procedure and site/side matches the consent form.
"][checkbox value="--Patient was involved in the site/side marking.
"][checkbox name="timeoutnexplanonremov" value="--For final timeout, physician paused or verbally confirmed with procedure team of:"][/conditional][conditional field="timeoutnexplanonremov" condition="(timeoutnexplanonremov).is('--For final timeout, physician paused or verbally confirmed with procedure team of:')"]
[textarea cols="100" rows="3"]---correct patient, correct procedure, and correct site/side.
---The patient has been positioned correctly for the procedure.
---All necessary equipment are available.[/textarea]
[/conditional][conditional field="ProcType" condition="(ProcType).is('NEXPLANON REMOVAL')"][checkbox value="--Instrument sterility verified.
"]
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.
-Above anesthetic agent 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')"]
DIAGNOSIS: Z30.46 Encounter for surveillance of implantable subdermal
contraceptive

PROCEDURE: Removal with reinsertion of nexplanon - CPT 11983
NEXPLANON LOT#: [text size="20"]
ANESTHESIA AGENT(S): [checkbox value="Lidocaine 1% with epinephrine|Lidocaine 1% without epinephrine|Lidocaine 2% with epinephrine|Lidocaine 2% without epinephrine|Marcaine 0.5%|Bicarbonate buffering solution"]
-Total amt used: [text size="5"] ml
[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 to include ensuring: [comment memo="only select what's applicable" memo_size="small"]
[checkbox value="--Patient was identified using full name and DOB.
"][checkbox value="--Patient was evaluated and medical record reviewed including history and lab/imaging findings if applicable.
"][checkbox value="--Procedure and site/side matches the consent form.
"][checkbox value="--Patient was involved in the site/side marking.
"][checkbox name="timeoutnexplanonreins" value="--For final timeout, physician paused or verbally confirmed with procedure team of:"][/conditional][conditional field="timeoutnexplanonreins" condition="(timeoutnexplanonreins).is('--For final timeout, physician paused or verbally confirmed with procedure team of:')"]
[textarea cols="100" rows="3"]---correct patient, correct procedure, and correct site/side.
---The patient has been positioned correctly for the procedure.
---All necessary equipment are available.[/textarea]
[/conditional][conditional field="ProcType" condition="(ProcType).is('NEXPLANON REMOVAL/REINSERTION')"][checkbox value="--Instrument sterility verified.
"]
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.
-Above anesthetic agent 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 value="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][conditional field="ProcType" condition="(ProcType).is('COLPOSCOPY')"]
PRE-OP DIAGNOSIS: [select value="|ASCUS - R87.610|ASC-H - R87.611|LSIL - R87.612|HSIL - R87.613|AGC - R87.619"][select value="|, Positive for High risk HPV"]
PRE-OP DIAGNOSIS: [select value="|ASCUS - R87.610|ASC-H - R87.611|LSIL - R87.612|HSIL - R87.613|AGC - R87.619"][select value="|, Positive for High risk HPV"]
PROCEDURE: [select value="Colposcopy (with biopsy) - 57455|Colposcopy with ECC - 57454|Colposcopy with ECC (no visible cervical lesions biopsied) - 57456"]
ANESTHESIA: [text default="none" size="40"]
[checkbox name="ColpoSup" value="Supervising Physician:"][/conditional][conditional field="ColpoSup" condition="(ColpoSup).is('Supervising Physician:')"] Dr. [text size="20"]
[/conditional][conditional field="ProcType" condition="(ProcType).is('COLPOSCOPY')"]
INDICATIONS/COUNSELING:
-Discussed the reasons for this procedure which include: abnormal pap, determining future risk of progression to cervical cancer.
-Discussed the risks of this procedure which include but are not limited to:
--bleeding possibly necessitating application of Monsels solution
--infection possibly necessitating antibiotic therapy
--allergic reaction to the solutions used in the procedure
--possibility that the test may not detect premalignant/malignant conditions (false-negative)
-Discussed alternatives to procudure which include: continued observation with PAP smears, referral for gynecologist/second opinion.
-Discussed expections for post-operative period:
--necessary recuperation time period of <1day
--bleeding, brown discharge and some cramping which may persist for 1-2 days if biopsies are taken.
-Timeframe/mode of followup for discussing results of potential biopsies was discussed.
-Patient acknowledged understanding of the items above and patient agrees to proceed.
-Consent form was signed as hardcopy to be scanned into patient's record.
-A time out was performed prior to the procedure and documented in a hardcopy form to be scanned into patient's record to include ensuring: [comment memo="only select what's applicable" memo_size="small"]
[checkbox value="--Patient was identified using full name and DOB.
"][checkbox value="--Patient was evaluated and medical record reviewed including history and lab/imaging findings if applicable.
"][checkbox value="--Procedure and site/side matches the consent form.
"][checkbox value="--Patient was involved in the site/side marking.
"][checkbox name="timeoutcolpo" value="--For final timeout, physician paused or verbally confirmed with procedure team of:"][/conditional][conditional field="timeoutcolpo" condition="(timeoutcolpo).is('--For final timeout, physician paused or verbally confirmed with procedure team of:')"]
[textarea cols="100" rows="3"]---correct patient, correct procedure, and correct site/side.
---The patient has been positioned correctly for the procedure.
---All necessary equipment are available.[/textarea]
[/conditional][conditional field="ProcType" condition="(ProcType).is('COLPOSCOPY')"][checkbox value="--Instrument sterility verified.
"]
PROCEDURE
-The speculum was inserted and the cervix was identified.
-Utilizing adequate magnification with colposcope, the entire transformation zone and squamocolumnar junction [select value="were|were NOT"] visualized.
-[select value="Acetic acid solution then lugol's iodine solution were|Acetic acid solution was"] applied sequentially to cervix and cervix reexamined.
-[select name="colpolesions" value="Lesions adequately identified as described in findings|No lesions visualized"]

FINDINGS:
-Vagina: [text default="normal vaginal mucosa without lesions or evidence of genital warts." size="50"]
-External genitalia: [text default="normal" size="50"]
-Perirectal exam: [text default="normal" size="50"]
-Cervix exam without then with [select value="acetic acid & Lugol's iodine solution|acetic acid solution"], the following lesion(s) identified and biopsied:
[checkbox name="colpolesion1" value="*Lesion/Specimen 1/A"][/conditional][conditional field="colpolesion1" condition="(colpolesion1).is('*Lesion/Specimen 1/A')"] at [text size="5"] o'clock position:
--Size- [select value="small patch|large patch"]
--Margins- [select value="sharp|indistinct"]
--Color- [select value="bright white|dull/pearly gray"]
--Punctations- [select name="punc1" value="none|small|large"][/conditional][conditional field="punc1" condition="(punc1).isNot('none')"] caliber, [select value="sparse|numerous"][/conditional][conditional field="colpolesion1" condition="(colpolesion1).is('*Lesion/Specimen 1/A')"]
--Mosaicism - [select value="not present|PRESENT"]
--Abnormal Vessels- [select name="abnves1" value="none|uniform|sporadic"][/conditional][conditional field="abnves1" condition="(abnves1).isNot('none')"], [select value="sparse|numerous"], [select value="small|large"] caliber
[/conditional][conditional field="ProcType" condition="(ProcType).is('COLPOSCOPY')"]
[checkbox name="colpolesion2" value="*Lesion/Specimen 2/B"][/conditional][conditional field="colpolesion2" condition="(colpolesion2).is('*Lesion/Specimen 2/B')"] at [text size="5"] o'clock position:
--Size- [select value="small patch|large patch"]
--Margins- [select value="sharp|indistinct"]
--Color- [select value="bright white|dull/pearly gray"]
--Punctations- [select name="punc2" value="none|small|large"][/conditional][conditional field="punc2" condition="(punc2).isNot('none')"] caliber, [select value="sparse|numerous"][/conditional][conditional field="colpolesion2" condition="(colpolesion2).is('*Lesion/Specimen 2/B')"]
--Mosaicism - [select value="not present|PRESENT"]
--Abnormal Vessels- [select name="abnves2" value="none|uniform|sporadic"][/conditional][conditional field="abnves2" condition="(abnves2).isNot('none')"], [select value="sparse|numerous"], [select value="small|large"] caliber
[/conditional][conditional field="ProcType" condition="(ProcType).is('COLPOSCOPY')"]
[checkbox name="colpolesion3" value="*Lesion/Specimen 3/C"][/conditional][conditional field="colpolesion3" condition="(colpolesion3).is('*Lesion/Specimen 3/C')"] at [text size="5"] o'clock position:
--Size- [select value="small patch|large patch"]
--Margins- [select value="sharp|indistinct"]
--Color- [select value="bright white|dull/pearly gray"]
--Punctations- [select name="punc3" value="none|small|large"][/conditional][conditional field="punc3" condition="(punc3).isNot('none')"] caliber, [select value="sparse|numerous"][/conditional][conditional field="colpolesion3" condition="(colpolesion3).is('*Lesion/Specimen 3/C')"]
--Mosaicism - [select value="not present|PRESENT"]
--Abnormal Vessels- [select name="abnves3" value="none|uniform|sporadic"][/conditional][conditional field="abnves3" condition="(abnves3).isNot('none')"], [select value="sparse|numerous"], [select value="small|large"] caliber
[/conditional][conditional field="ProcType" condition="(ProcType).is('COLPOSCOPY')"]
[checkbox name="colpolesion4" value="*Lesion/Specimen 4/D"][/conditional][conditional field="colpolesion4" condition="(colpolesion4).is('*Lesion/Specimen 4/D')"] at [text size="5"] o'clock position:
--Size- [select value="small patch|large patch"]
--Margins- [select value="sharp|indistinct"]
--Color- [select value="bright white|dull/pearly gray"]
--Punctations- [select name="punc4" value="none|small|large"][/conditional][conditional field="punc4" condition="(punc4).isNot('none')"] caliber, [select value="sparse|numerous"][/conditional][conditional field="colpolesion4" condition="(colpolesion4).is('*Lesion/Specimen 4/D')"]
--Mosaicism - [select value="not present|PRESENT"]
--Abnormal Vessels- [select name="abnves4" value="none|uniform|sporadic"][/conditional][conditional field="abnves4" condition="(abnves4).isNot('none')"], [select value="sparse|numerous"], [select value="small|large"] caliber[/conditional][conditional field="ProcType" condition="(ProcType).is('COLPOSCOPY')"]
-Entirety of lesion(s) [select value="were|were NOT"] visualized.
[checkbox value="-Pap smear was repeated.
"][checkbox value="-Endocervical curretage was performed.
"][checkbox value="-Endometrial biopsy was performed.
"][/conditional][conditional field="ProcType" condition="(ProcType).is('ENDOMETRIAL BIOPSY')"]
PRE-OP DIAGNOSIS: [select value="N93.8 - Other specified abnormal uterine and vaginal bleeding|"][text size="60"]
FINDINGS: [select value="none|"][text size="60"]
POST-OP DIAGNOSIS: [select value="N93.8 - Other specified abnormal uterine and vaginal bleeding|"][text size="60"]
PROCEDURE: Endometrial biopsy - CPT 58100
ANESTHESIA: [select value="none|"][text size="60"]
[checkbox name="EMBSup" value="Supervising Physician:"][/conditional][conditional field="EMBSup" condition="(EMBSup).is('Supervising Physician:')"] Dr. [text size="20"]
[/conditional][conditional field="ProcType" condition="(ProcType).is('ENDOMETRIAL BIOPSY')"]
INDICATIONS/COUNSELING:
-Reason(s) for this procedure: [checkbox value="evaluation of abnormal uterine bleeding|evaluation of post-menopausal bleeding|evaluation of abnormal endometrial cells found on a Pap smear"]. [text size="50"]
-Discussed with patient the risks of this procedure which include: bleeding, infection, pain, and need for repeat procedure.
-Discussed with patient the alternatives to this procedure which include: referral for gynecologist/second opinion.
-Verified patient's non-pregnancy status by negative [select value="serum|urine"] HCG.
-Verified that all patient's questions were answered. No guarantees were given or implied.
-Consent form was signed as hardcopy to be scanned into patient's record.
-A time out was performed prior to the procedure and documented in a hardcopy form to be scanned into patient's record to include ensuring: [comment memo="only select what's applicable" memo_size="small"]
[checkbox value="--Patient was identified using full name and DOB.
"][checkbox value="--Patient was evaluated and medical record reviewed including history and lab/imaging findings if applicable.
"][checkbox value="--Procedure and site/side matches the consent form.
"][checkbox value="--Patient was involved in the site/side marking.
"][checkbox name="timeoutEMB" value="--For final timeout, physician paused or verbally confirmed with procedure team of:"][/conditional][conditional field="timeoutEMB" condition="(timeoutEMB).is('--For final timeout, physician paused or verbally confirmed with procedure team of:')"]
[textarea cols="100" rows="3"]---correct patient, correct procedure, and correct site/side.
---The patient has been positioned correctly for the procedure.
---All necessary equipment are available.[/textarea]
[/conditional][conditional field="ProcType" condition="(ProcType).is('ENDOMETRIAL BIOPSY')"][checkbox value="--Instrument sterility verified.
"]
PROCEDURE
[checkbox name="bimanual1" value="-Bimanual exam was performed and position of uterus determined to be "][/conditional][conditional field="bimanual1" condition="(bimanual1).is('-Bimanual exam was performed and position of uterus determined to be ')"][select value="midposition|anteroverted|posteroverted"].
[/conditional][conditional field="ProcType" condition="(ProcType).is('ENDOMETRIAL BIOPSY')"]-The speculum was inserted and the cervix was identified.
-[select value="Betadine/Iodine|Chlorhexidine"] was used to clean the cervix.
[checkbox value="-An os dilator was used.
"]-[select memo="choose whether tenaculum used" memo_size="small" name="tenaculum3" value="|A tenaculum was applied to |A tenaculum was not used. "][/conditional][conditional field="tenaculum3" condition="(tenaculum3).is('A tenaculum was applied to ')"][select value="superior/anterior cervix. |posterior/inferior cervix."][/conditional][conditional field="ProcType" condition="(ProcType).is('ENDOMETRIAL BIOPSY')"]
-The uterus was sounded to a depth of [text size="5"]cm.
-The endometrial biopsy pipelle was inserted into the uterus and a 360 degree endometrial sample was obtained in the usual manner.
[checkbox value="-The procedure was repeated to obtain a second sample.
"][checkbox value="-A cytobrush was used to collect any sample remaining at the os.
"]-All samples were placed in a specimen container and sent to pathology for review.
[/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]
Chaperoneselect procedure

select for additional free text
Result - Copy and paste this output: