Home Forums Discussions General Discussion Where do I document procedure note

Where does it work best to document an inoffice procedure such as:
circumcision, removal of ear wax, or a foreign body,

a test procedure such as:
tympanogram,or pulmonary function test,

or in office lab tests such as:
strep test, or UA

And then some procedures or tests need to be tracked. what seems to work best to track the above

I would do an addendum and attach it to the note. I would make a template so that I could modify when needing to document the same procedure for future patients.
On the summary page there is an area for tracked data. You can go into administrative options and make a list for the data that you would like to track. You can also always use the same exact wording in notes and go to reports and generate reports that way. You could track strep test if you use those words every time.

Thank you,
I can see the addendum and the summary. I think this will work well for me.
But, I am not sure what you mean by:
"You can also always use the same exact wording in notes and go to reports and generate reports that way. You could track strep test if you use those words every time."

I think he means that since the reports include the ability to run a report on any words within the text of notes on AC you can run a report on "strep test". The report will give you a list of all notes that contain this word. Like you can run a report for all HPIs that have the word "pain".

We put in-office procedures in the physical exam section. Never thought of doing an addendum.

WE put labs in notes. Procedures usually are an addendum, but can easily be as a part of PE.

I don't think there is a single correct way, this is personal preference. Both notes and addendems can show up as a separate note under past encounters and any good string can be searched.

I agree with Wendell and St. Lawrence, and think an addendum for procedures is the way to go. That way they are listed neatly, chronologically and easy to see in the past encounters box. A negative is that they are all called "addendum" and are interspersed with notes and messages.

When you go to do addendum from a progress note you can change it to 'procedure' at the top - then it shows up as 'procedure note'.

Thanks Steven! I never noticed that option. It helps....

Thanks for the great idea about putting the procedure note in an addendum. I have been putting them in the assessment section.

I wish the Addendum would allow the importing of a picture. If I take a picture of a lesion or the like I do not always get it imported before I sign off the chart. It would be helpful if I could name the Addendum "Picture" and upload it there.

I also think it would be great to import a picture to the addendum

I document procedures in the Assessement section.
I have several standardized type skin procedure notes that I have templated.
Skin biopsy, skin cryo-destruction, skin electrodessication & curettage, skin excision, toenail resection.

I also have templates for trigger point inj, joint inj, tendon inj, osteopathic manipulation.

There are more, but these are some commonly used ones that we have.