Jason's procedure dot phrases

Jason sent out some of his favorite procedure and counseling dot phrases. He notes, "I use them all the time. Some are complete visit notes (the ones that usually will have a scheduled procedure), others are just procedure notes (the ones I usually just squeeze into the appointment). I've included my names for them as well, but feel free to adapt to your own technique and make into your own phrases if you want."

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(jprocbx)

.id presents for biopsy of skin lesion.

Informed consent obtained. Area prepped and draped in sterile fashion. ***cc lidocaine + epi and bicarb administered intradermally. Using ***mm punch, bx done without difficulty and sent to pathology. *** sutures placed using 4-0 vicryl. Area dressed with abx ointment and bandaid. Pt tolerated procedure well.

Pt instructed to leave dressing on until tomorrow, then take off and leave open as desired. Keep clean with soap and water. Return in 1 week for suture removal. Watch for signs of infection (hot, red, pus draining, fever, etc).
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(jproccast) I also use this one for splinting too. Example "short arm thumb spica cast applied to RUE…."

*** applied to ***. Sensation and circulation is intact post application. Care instructions were given.
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(jproccirc)

.id presents for circumcision.

Informed consent obtained from parent. Pt placed on circumcision board.
Area prepped and draped in sterile fashion. 1cc lidocaine administered in ring block at base of phallus. Circumcision done in usual fashion with *** gomko. Minimal bleeding. No complications. Pt was dressed with vaseline gauze. Pt tolerated procedure well.

Parent instructed to leave vaseline gauze on at least 1 hour and then to replace with another vaseline gauze afterwards. Discussed warning s/sx of bleeding and infection. F/u prn.
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(jproccryo) - for this one, I just add a number and an s if there are multiple lesions. I am sure to include in my exam the description of the lesions (location and dx) so that I don't have to refer to it here too.

cryotherapy to lesion described above x 3 freeze thaw cycles
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(jprocendometrialbx)

.id who presents for endometrial biopsy for post menopausal bleeding.

Informed consent obtained. Pt placed in lithotomy position. She had normal external female genitalia. Speculum exam reveals a healthy appearing vaginal vault and cervix without discharge. Pap was done. Cervix was cleaned with betadine and sounded to 6cm easily. Endometrial bx done in usual fashion with 2 passes. Bimanual exam is negative with normal sized and freely mobile uterus and unremarkable ovaries. Pt tolerated procedure well.

Pt to be contacted with results. If neg, anticipate just following sx. If rebleeds, may need u/s.
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(jprocganglioncyst) - for ganglion cyst aspirations

Informed consent verbally obtained. Area prepped with iodine and alcohol. Intradermal lidocaine with epi administered over ganglion. With large bore needle, approx ***cc viscous material aspirated from cyst reducing the size completely, then 5mg kenalog injected into cyst space. Area cleaned and bandaid placed. Pt tolerated procedure well.
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(jprocid) - for I+D

.PROCEDURE:
Informed consent obtained. Area prepped and draped in sterile fashion. Incision made with 11 blade approximately *** cm long. Purulent material expressed easily, swabbed and sent for culture. Pocket explored and irrigated. ***cm of ribbon gauze placed to allow drainage. Good hemostasis achieved. Area cleaned and antibiotic ointment placed over incision site then dressed. The patient tolerated the procedure well.

ASSESSMENT:
*** abscess s/p I+D

PLAN:
Sent for culture. Keep area clean. Return in *** days for removal of drain/wound care. Signs and symptoms of infection discussed.
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(jprocingrownnail)

.id presents for partial toenail removal for infected ingrown nails. {RIGHT/LEFT:16} {MEDIAL / LATERAL:10360} aspect of great toe nail ingrown with mild swelling and erythema of surrounding skin.

PROCEDURE:
Informed consent obtained. Area prepped with iodine and draped in sterile fashion. 10cc 1% lidocaine with 0.5% bupivocaine plus bicarb administered as digital block. Nail was elevated, and 1/4 of nail edge was cut and removed without difficulty. Drysol with pressure achieved good hemostasis. Area cleaned and antibiotic ointment placed over incision site then dressed. The patient tolerated the procedure well.

ASSESSMENT:
Partial nail removal

PLAN:
Reinforced cutting nails square, massage of skin off nail edges and warm soaks in future for prevention of further episodes. Signs and symptoms of infection discussed. Keep dressing on until tomorrow, then cover only as needed. Hot water soaks tid after that. Follow up prn.

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(jprocinjection) - based on how our injection rooms seem to be stocked, I'd guess that most of you use depomedrol instead. But this kind of dot phrase saves me a lot of time and addresses all the concerns that India had about out documentation.

Informed consent obtained. Area prepped with iodine and alcohol. Using sterile technique, injection into *** done using 27g needle administering ***mg kenalog, ***cc 2% lidocaine, ***cc bupivocaine. Pt tolerated well and felt some improvement in sx.
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(jprociud)

.id presents for IUD placement. See prior note for more details. She took ibuprofen 800mg prior to coming in.

Informed consent obtained. Pt placed in lithotomy position. Bimanual exam was negative, speculum inserted revealing normal vaginal mucosa and cervix without discharge. Area was prepped with iodine. Tenaculum was placed and the uterus was sounded. *** IUD placed in usual fashion without difficulty and strings were trimmed. Tenaculum was removed. Pt tolerated procedure well and there were no complications.

Pt instructed and taught to feel for the IUD string monthly to confirm retention of the IUD after menses. In addition, she is counseled to call or return for fever, worsening pain, unusually heavy vaginal bleeding, suspected expulsion, or foul vaginal discharge. Stressed STD prevention.

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(jproclaceration)

PROCEDURE:
Informed consent obtained. Area prepped with iodine and draped in sterile fashion. ***cc 1% lidocaine + epi administered locally. Laceration closed with *** interrupted sutures using 4-0 vicryl with good skin approximation. Minimal bleeding. Area cleaned and antibiotic ointment placed over incision site then dressed. The patient tolerated the procedure well.

PLAN:
discussed signs and symptoms of infection. Return to remove sutures in 5-7 days.

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(jprocsebcyst) - note that I include measurements of the cyst since that matters for coding. Also note that for most of these, I actually now use punch bx rather than scalpel.

.id presents for cyst removal. Cyst measures *** cm located on ***.

PROCEDURE:
Informed consent obtained. Area prepped and draped in sterile fashion. Local anesthetic with intradermal lidocaine with epinephrine. Shallow elliptical incision made with 15 blade approximately *** cm long. Sac removed in entirety with hemostat. Wound irrigated with normal saline. *** interrupted sutures placed using 4-0 vicryl. Good hemostasis achieved. Area cleaned and antibiotic ointment placed over incision site then dressed. The patient tolerated the procedure well.

ASSESSMENT:
sebaceous cyst

PLAN:
Keep area clean. Return for suture removal in *** days. Signs and symptoms of infection discussed. Follow up prn.

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Lastly, these are my counseling dot phrases. I call them J (all my dot phrases start with J), then 50 (for 50), then 3, 4, 5 (for level 3-5). The *** should be filled with content relevant to your discussion or a reference to that elsewhere in your note. Could also be coordination of care, but I find that most of my time dependent ones are more counseling related, so this suits me well.

j503new
More than 50% of this 30min face to face visit was spent counseling ***

j504
More than 50% of this 25min face to face visit was spent counseling ***

j504new
More than 50% of this 45min face to face visit was spent counseling ***

j505
More than 50% of this 40min face to face visit was spent counseling ***

j505new
More than 50% of this 60min face to face visit was spent counseling ***