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IMPRESSION / PLAN
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StartAssessment1
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1Assessment
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1Assessment #
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1Impression w/ icd10-MustSelect1
• • •
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1Impression Freetext
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1Impression.DDX
• • •
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1ImpressionDDX.FreeText
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1problem location
• • •
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1ImpressionLocationFreetext
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1 Enter Counseling Macro here
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1PIC1.2
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1PIC1.1
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1PIC1.3
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1PIC1.4
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1PIC1.5
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1Procedure Consent
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1. Pics Off/On
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1.Status - New / Improved / Worse?
• • •
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1OtherTreatment
• • •
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1Other-ifTxDeferred,SpecifyY.
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1PLAN: REMOVAL
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1Shave#of_mL_Lido
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1Removal- Malignant
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1REMOVAL - B9
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1Removal-Malig- Trunk,Ext
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1SIZE of lesion : Malig- Trunk,Extremity
• • •
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1Removal-Malig- Hand,Foot,Neck.
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1SIZE of lesion : Malig- Hand,Foot,Neck.
• • •
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1Removal-Malig- Face, mm
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1SIZE of lesion : Malig- Face, mm
• • •
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1Removal- B9- Trunk-Extremity
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1.B9 Size-Trunk-Extremity
• • •
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1Removal- B9- Hand,Foot,Neck.
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1.B9-Size- Hand,Foot,Neck.
• • •
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1Removal- B9- face- mm
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1.B9-Size-face- mm
• • •
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1Hemostasis + closing
• • •
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1.removal Addl notes
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1CRYO
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1CRYO- AK
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1.CRYO - AK & Qty
• • •
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1CRYO/PLASM. B9
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1.CRYO/PLASMA-B9 Lesion Type & Qty
• • •
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1CRYO/PLASMA. SkinTag
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1CRYO/PLASMA Skin Tag - #
• • •
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1.PlasmaPen ProcedureStatement
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1CRYO # of Frz / Thaw Cycles
• • •
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1Cryo#of_mL_Lido
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1Treatment #
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1CRYO- ADDL NOTES
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1DESTRUCTION MALIGNANT LESION
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1Destruction CRYO
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1Destruction#of_mL_Lido
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1CRYO - Trunk, Arm, Legs
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1SIZE of lesion : Trunk, Arms, Legs
• • •
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1CRYO - Scalp, Neck, Hands, Feet
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1SIZE of lesion : Scalp, Neck, Hands, Feet
• • •
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1CRYO - Face, Ears, Eyelids, Nose, Lip
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1SIZE of lesion : Face, Ears, Eyelids, Nose, Lip
• • •
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1# of Frz / Thaw Cycles
• • •
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1Cryo - BCC
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1cryo - BCC - Loc
• • •
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1Cryo - SCC
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1cryo - SCC - Loc
• • •
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Cryo1 - SCCIS
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1cryo - SCCIS - Loc
• • •
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1.1DestructionTreatment #
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1destructionCRYO- ADDL NOTES
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1Destruction RF
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1Destruction#of_mL_Lido
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1RF - Trunk, Arm, Legs
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1SIZE of lesion : Trunk, Arms, Legs
• • •
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1RF - Scalp, Neck, Hands, Feet
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1SIZE of lesion : Scalp, Neck, Hands, Feet
• • •
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1RF - Face, Ears, Eyelids, Nose, Lip
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1SIZE of lesion : Face, Ears, Eyelids, Nose, Lip
• • •
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1# of RF Applications
• • •
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1RF - BCC
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1BCC - location
• • •
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1RF - SCC
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1SCC - Location
• • •
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1RF - Other/ NUB
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1RF Notes
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1DNA WOUND SWAB
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1DNA Addl Notes
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1OTC Tx Regimen
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1OTC Topicals
• • •
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1OTC Tx Addl Notes
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1PRESCRIPTION
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1Prescriptions
• • •
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1Prescription Addl Notes
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1.5FU INJECTION
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1Treatment #
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1Lot #:
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1Consent Obtained?
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1LESION TYPE
• • •
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1QTY of MLs
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1.5FU Addl Notes
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1DermTech Adhesive Biopsy
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1DermTech Addl Notes
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1VaccineAdmin/ Med Injection
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1VaccineType
• • •
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1InjectionSite
• • •
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1VaccineTreatment#
• • •
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1GTIN: _____
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1NDC: _____
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1Lot #: ______
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1Expiration Date:
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1injectionProcedure(AutoPop)
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Total MLs injected
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1.2DrugInjectedType
• • •
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1InjectionType SQ or IM
• • •
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1InjectionAddl Notes
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1.Kenalog Injection
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1Consent obtained?
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1. # of lesions/ IM injections
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1Kenalog.IM or LesionType
• • •
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1INJECTION SITE
• • •
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1Kenalog ML/volume
• • •
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1Kenalog Type/ concentration
• • •
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1Qty of lido mixed?
• • •
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1Total volume inj w/ lido
• • •
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1Lot #
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1Expiration Date
/
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1Kenalog Addl Notes
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1 Debridement
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1Size: L mm x W mm x D mm
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1Blade used
• • •
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1Drainage Type&Amount
• • •
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1Dressing type
• • •
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1Debridement Addl Notes
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1Dressing Change Performed
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1dressing change loc
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1Dressing type
• • •
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1Dressing Change Addl Notes
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1PLAN: I&D/FreeText/ ChemicalPeel
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1Write_I&D/Peel/Other
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Chemical Peel Consent
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1.FreeTxt Plan Details
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1.I&D PlanDetails
• • •
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1.Lesion Type
• • •
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1.PlanFreeTxt_ LocationSame
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1.PlnFreeTxt.AddlNotes
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SELECT ALL IF DOING A PEEL!
• • •
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Chemical Peel Done Today
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Post Treatment Instructions Give
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1.Chemical Peel additional
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1# of ML Lidocaine
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1PLAN: Nail Procedure
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Select Nail Procedure
• • •
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Location
• • •
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1Nail.Notes
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1Dressing Change Regimen
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1DressingRegimen
• • •
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1Dressing type
• • •
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1Dressing Regimen Addl Notes
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StartAssessment2
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2Assessment
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2Assessment #
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2Impression w/ icd10-MustSelect1
• • •
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2Impression Freetext
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2Impression.DDX
• • •
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2ImpressionDDX.FreeText
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2problem location
• • •
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2ImpressionLocationFreetext
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2 Enter Counseling Macro here
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2PIC2.1
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2PIC2.2
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2PIC2.3
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2PIC2.4
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2PIC2.5
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2Procedure Consent
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2. Pics On/Off
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2.Status - New / Improved / Worse?
• • •
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2OtherTreatment
• • •
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2Other.ifTxDeferred,SpecifyY.
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2PLAN: REMOVAL
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2Shave#of_mL_Lido
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2.Removal- Malignant
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2.removal - B9
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2.removal-Malig- Trunk,Extremity
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2SIZE of lesion : Malig- Trunk,Extremity
• • •
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2.removal-Malig- Hand,Foot,Neck.
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2SIZE of lesion : Malig- Hand,Foot,Neck.
• • •
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2.removal-Malig- Face, mm
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2SIZE of lesion : Malig- Face, mm
• • •
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2.removal- B9- Trunk-Extremity
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2.size- B9 -Trunk-Extremity
• • •
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2.removal- B9- Hand,Foot,Neck.
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2.size- B9- Hand,Foot,Neck.
• • •
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2.removal- B9- face- mm
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2.size- B9- face- mm
• • •
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2Hemostasis + closing
• • •
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2.removal Addl notes
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2CRYO
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2CRYO- AK
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2CRYO - AK & Qty
• • •
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2CRYO/PLASM. B9
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2CRYO/PLASMA-B9 Lesion Type & Qty
• • •
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2CRYO/PLASMA. SkinTag
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2CRYO/PLASMA Skin Tag - #
• • •
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2PlasmaPen ProcedureStatement
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2CRYO # of Frz / Thaw Cycles
• • •
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2LIDO # of ML
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2CRYO- ADDL NOTES
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2DESTRUCTION MALIGNANT LESION
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2DESTRUCTION CONSENT
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2Destruction CRYO
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2DestructMalignant
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2CRYO - Trunk, Arm, Legs
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2SIZE of lesion : Trunk, Arms, Legs
• • •
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2CRYO - Scalp, Neck, Hands, Feet
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2SIZE of lesion : Scalp, Neck, Hands, Feet
• • •
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2CRYO - Face, Ears, Eyelids, Nose, Lip
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2SIZE of lesion : Face, Ears, Eyelids, Nose, Lip
• • •
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2# of Frz / Thaw Cycles
• • •
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2Cryo - BCC
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2cryo - BCC - Loc
• • •
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2Cryo - SCC
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2cryo - SCC - Loc
• • •
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2Cryo - SCCIS
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2cryo - SCCIS - Loc
• • •
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2.DestructionTreatment #
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2destructionCRYO- ADDL NOTES
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2DNA WOUND SWAB
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2DNA Addl Notes
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2Debridement
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2Size: L mm x W mm x D mm
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2Blade used
• • •
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2Drainage Type&Amount
• • •
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2Dressing type
• • •
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2DebridementAddl Notes
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2Dressing Change Performed
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2Dressing change location
• • •
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2Dressing type
• • •
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2Dressing Change Addl Notes
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2Dressing Change Regimen
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2Regimens
• • •
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2Dressing type
• • •
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2DressigRegimen Addl Notes
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2OTC Tx Regimen
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2OTC Topicals
• • •
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2OTC tx Addl Notes
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2PRESCRIPTION
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2Prescriptions
• • •
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2Prescription Addl Notes/ Sig
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2.5FU INJECTION
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2Treatment #
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2Lot #:
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2Consent Obtained?
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2LESION TYPE
• • •
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2QTY of MLs
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2.5FU Addl Notes
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2DermTech Adhesive Biopsy
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2DermTech Addl Notes
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2Intralesional Kenalog Injection
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2Consent obtained?
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2. # of lesions injected
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2Kenalog Lesion Type
• • •
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2INJECTION SITE
• • •
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2Kenalog ML/volume
• • •
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2Kenalog Type/ concentration
• • •
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2Qty of lido mixed?
• • •
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2Total volume inj w/ lido
• • •
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2Lot #
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2Expiration Date
/
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2Kenalog Addl Notes
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2PLAN: I&D or FreeText___
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2WritePlanNameHere_
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2.FreetxtPlanDetails
• • •
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2.FreeTxt Plan Details
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2.Lesion Type
• • •
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2.PlanFreeTxt_ LocationSame
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2.PlnFreeTxt.AddlNotes
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StartAssessment3
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3Assessment
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3Assessment #
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3Impression w/ icd10.MustSelect1
• • •
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3Impression Freetext
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3Impression.DDX
• • •
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3ImpressionDDX.FreeText
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3problem location
• • •
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3ImpressionLocationFreetext
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3 Enter Counseling Macro here
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3PIC3.1
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3PIC3.2
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3PIC3.3
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3PIC3.4
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3PIC3.5
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3Procedure Consent
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3.Pics On/Off
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3.Problem Status - Improved / Worse?
• • •
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3OtherTreatment
• • •
|
3Other.ifTxDeferred,SpecifyY.
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3PLAN: REMOVAL
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3Removal#of_mL_Lido
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3.removal- Malignant
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3.removal - B9
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|
3.Removal-Malig- Trunk,Extremity
|
3SIZE of lesion : Malig- Trunk,Extremity
• • •
|
|
3.Removal-Malig- Hand,Foot,Neck.
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3SIZE of lesion : Malig- Hand,Foot,Neck.
• • •
|
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3.removal-Malig- Face, mm
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3SIZE of lesion : Malig- Face, mm
• • •
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3.removal- B9- Trunk-Extremity
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3.size- B9 -Trunk-Extremity
• • •
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3.removal- B9- Hand,Foot,Neck.
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3.size- B9- Hand,Foot,Neck.
• • •
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3.removal- B9- face- mm
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3.size- B9- face- mm
• • •
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3Hemostasis + closing
• • •
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3removal Addl notes
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3CRYO
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3CRYO- AK
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3CRYO - AK & Qty
• • •
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3CRYO/PLASM. B9
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3CRYO/PLASMA-B9 Lesion Type & Qty
• • •
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3CRYO/PLASMA. SkinTag
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3CRYO/PLASMA Skin Tag - #
• • •
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3PlasmaPen ProcedureStatement
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3CRYO # of Frz / Thaw Cycles
• • •
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3LIDO # of ML
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3CRYO- ADDL NOTES
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3DESTRUCTION MALIGNANT LESION
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3DESTRUCTION CONSENT
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3Destruction CRYO
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3cryoi#of_mL_Lido
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3CRYO - Trunk, Arm, Legs
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3SIZE of lesion : Trunk, Arms, Legs
• • •
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3CRYO - Scalp, Neck, Hands, Feet
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3SIZE of lesion : Scalp, Neck, Hands, Feet
• • •
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3CRYO - Face, Ears, Eyelids, Nose, Lip
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3SIZE of lesion : Face, Ears, Eyelids, Nose, Lip
• • •
|
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3# of Frz / Thaw Cycles
• • •
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3Cryo - BCC
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3cryo - BCC - Loc
• • •
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3Cryo - SCC
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3cryo - SCC - Loc
• • •
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3Cryo - SCCIS
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3cryo - SCCIS - Loc
• • •
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3.DestructionTreatment #
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3destructionCRYO- ADDL NOTES
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3DNA WOUND SWAB
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3DNA Addl Notes
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3 Debridement
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3Size: L mm x W mm x D mm
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3Blade used
• • •
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3Drainage Type&Amount
• • •
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3Dressing type
• • •
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3Debridement Addl Notes
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3Dressing Change Performed
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3Dressing change location
• • •
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3Dressing type
• • •
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3Dressing Chng Addl Notes
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3Dressing Change Regimen
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3Regimens
• • •
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3Dressing type
• • •
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3Dressing Regimn Addl Notes
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3OTC Tx Regimen
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3OTC Topicals
• • •
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3OTC tx Addl Notes/Sig
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3PRESCRIPTION
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3Prescriptions
• • •
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3RX Addl Notes
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3.5FU INJECTION
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3Treatment #
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3Lot #:
|
3Consent Obtained?
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3LESION TYPE
• • •
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3QTY of MLs
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3.5FU Addl Notes
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3DermTech Adhesive Biopsy
|
3DermTech Addl Notes
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3Intralesional Kenalog Injection
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3Consent obtained?
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3. # of lesions injected
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3Kenalog Lesion Type
• • •
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3INJECTION SITE
• • •
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3Kenalog ML/volume
• • •
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3Kenalog Type/ concentration
• • •
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3Qty of lido mixed?
• • •
|
|
3Total volume inj w/ lido
• • •
|
3Lot #
|
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3Expiration Date
/
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|
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3Kenalog Addl Notes
|
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|
3PLAN: I&D or FreeText___
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3WritePlanName I&D/OTher
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3.FreetxtPlanDetails
• • •
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3.FreeTxt Plan Details
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3.Lesion Type
• • •
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3.PlanFreeTxt_ LocationSame
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3.PlnFreeTxt.AddlNotes
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StartAssessment4
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4Assessment
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4Assessment #
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4Impression w/ icd10.MustSelect1
• • •
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4Impression Freetext
|
|
4Impression.DDX
• • •
|
4ImpressionDDX.FreeText
|
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4problem location
• • •
|
4ImpressionLocationFreetext
|
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4 Enter Counseling Macro here
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4PIC4.1
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4PIC4.2
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4PIC4.3
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4PIC4.4
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4PIC4.5
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4Procedure Consent
|
|
4.Pic On/Off
|
4.Problem Status Improved / Worse?
• • •
|
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4OtherTreatment
• • •
|
4Other.ifTxDeferred,SpecifyY.
|
|
4PLAN: REMOVAL
|
4.removal#of_mL_Lido
|
|
4.removal- Malignant
|
4.removal - B9
|
|
4.removal-Malig- Trunk,Extremity
|
4.removal of lesion : Malig- Trunk,Extremity
• • •
|
|
4.removal-Malig- Hand,Foot,Neck.
|
4SIZE of lesion : Malig- Hand,Foot,Neck.
• • •
|
|
4.removal-Malig- Face, mm
|
4SIZE of lesion : Malig- Face, mm
• • •
|
|
4.removal- B9- Trunk-Extremity
|
4.size- B9 -Trunk-Extremity
• • •
|
|
4.removal- B9- Hand,Foot,Neck.
|
4.size- B9- Hand,Foot,Neck.
• • •
|
|
4.removal- B9- face- mm
|
4.size- B9- face- mm
• • •
|
|
4Hemostasis + closing
• • •
|
4.removal Addl notes
|
|
4CRYO
|
|
|
4CRYO- AK
|
4CRYO - AK & Qty
• • •
|
|
4CRYO/PLASM. B9
|
4CRYO/PLASMA-B9 Lesion Type & Qty
• • •
|
|
4CRYO/PLASMA. SkinTag
|
4CRYO/PLASMA Skin Tag - #
• • •
|
|
4PlasmaPen ProcedureStatement
|
4CRYO # of Frz / Thaw Cycles
• • •
|
|
4LIDO # of ML
|
4CRYO- ADDL NOTES
|
|
4DESTRUCTION MALIGNANT LESION
|
|
|
4Destruction CRYO
|
4cryo#of_mL_Lido
|
|
4CRYO - Trunk, Arm, Legs
|
4SIZE of lesion : Trunk, Arms, Legs
• • •
|
|
4CRYO - Scalp, Neck, Hands, Feet
|
4SIZE of lesion : Scalp, Neck, Hands, Feet
• • •
|
|
4CRYO - Face, Ears, Eyelids, Nose, Lip
|
4SIZE of lesion : Face, Ears, Eyelids, Nose, Lip
• • •
|
|
4# of Frz / Thaw Cycles
• • •
|
|
|
4Cryo - BCC
|
4cryo - BCC - Loc
• • •
|
|
4Cryo - SCC
|
4cryo - SCC - Loc
• • •
|
|
4Cryo - SCCIS
|
4cryo - SCCIS - Loc
• • •
|
|
4.DestructionTreatment #
|
4destructionCRYO- ADDL NOTES
|
|
4DNA WOUND SWAB
|
4DNA Addl Notes
|
|
4Debridement
|
4Size: L mm x W mm x D mm
|
|
4Blade used
• • •
|
4Drainage Type&Amount
• • •
|
|
4Dressing type
• • •
|
4Debridement Addl Notes
|
|
4Dressing Change Performed
|
4Dressing change location
• • •
|
|
4Dressing type
• • •
|
4Dressing Chng Addl Notes
|
|
4Dressing Change Regimen
|
4DressingRegimen/ Orders
• • •
|
|
4Dressing type
• • •
|
4Dressing Regimn Addl Notes
|
|
4OTC Tx Regimen
|
4OTC Topicals
• • •
|
|
4OTC reg Addl Notes
|
|
|
4PRESCRIPTION
|
4Prescriptions
• • •
|
|
4Prescription Addl Notes
|
|
|
4.5FU INJECTION
|
4Treatment #
|
|
4Lot #:
|
4Consent Obtained?
|
|
4LESION TYPE
• • •
|
4QTY of MLs
|
|
|
4.5FU Addl Notes
|
|
4DermTech Adhesive Biopsy
|
4DermTech Addl Notes
|
|
4Intralesional Kenalog Injection
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4Consent obtained?
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4. # of lesions injected
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4Kenalog Lesion Type
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4INJECTION SITE
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4Kenalog ML/volume
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4Kenalog Type/ concentration
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4Qty of lido mixed?
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4Total volume inj w/ lido
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4Lot #
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4Expiration Date
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4Kenalog Addl Notes
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4PLAN: I&D or FreeText___
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4WritePlanNameHere_
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4.FreetxtPlanDetails
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4.FreeTxt Plan Details
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4.Lesion Type
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4.PlanFreeTxt_ LocationSame
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4.PlnFreeTxt.AddlNotes
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StartFollowUp
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Instruction | Pt Education | Addl Pics
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CRYO AFTERCARE SHEET
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Discussed ABCDEs (ON)
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Education Comments
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Education
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Education Comments
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Education
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Education Comments
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A: Visit/Aftercare Discussed With Who?
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B: Write First Name Here
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C: <--CommForm2Same Person?
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D: Other Indv Name/Addl Notes
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XL Communication Form/ Visit Summary
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BlankRecordsRelease
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addl pic1
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addl pic2
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addl pic3
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addl pic4
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1Follow up:
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Follow up
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Follow Up Priority Lvl
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1Reason for follow up
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FU4Impression1
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FU4Impression1freetext
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FU4Impression1.Location
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1status
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FU4Impression2
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FU4Impression2freetext
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FU4Impression2.Location
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2status
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FU4Impression3
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FU4Impression3freetext
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FU4Impression3.Location
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3status
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FU4Impression4
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FU4Impression4freetext
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FU4Impression4.Location
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4status
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FU Addl Notes
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Est. FU Time.Select1. A=15.B=30.C=45.D=60
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Est. FU Visit Time Needed
• • •
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Nxt Appt Appropriate 4 Telehealth?
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1.TurnPics OFF b4 Faxing
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Ai Documentation Stmnt
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Select Procedures Performed Today
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Procedure performed1
• • •
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Quantity Performed1
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Procedure performed2
• • •
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Quantity Performed2
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Procedure performed3
• • •
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Quantity Performed3
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Procedure performed4
• • •
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Quantity Performed4
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Procedure performed Addl Notes
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TOTAL VISIT [Time Breakdown Required]
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0.Visit Level: Time
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1. Reconciling Meds
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1. # of minutes spent
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2.Rvw Ext.notes,path,swab,labs,imging
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2. # of minutes spent
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3. Hx frm Fam,CG,FacStaff,RN,Medtch
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3. # of minutes spent
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4. Total f2f time (w / Pt / MPOA)
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4. # of minutes spent
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5.Charting,eRx,VisitSumry,Orders,CoordCare
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5. # of minutes spent
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NEW TotalVisitTime: Home, ALF, MC, GrpHm
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TotalVisitTime:SkilledNursing
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Virtual.PhoneE/M TimeSpent
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Telehealth Virtual Time Spent
• • •
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1Visit Level By MDM
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Visit Level by MDM - Select the appropriate qualifying options
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ModerateComplexity.New=60m. Est=40m
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HighComplexity.New=75m.Est=60m
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ModerateComplexity: Is 1 being addressed at visit?
• • •
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HIGHComplexity: Is 1 being addressed at visit?
• • •
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ModerateData: must meet 1 category
• • •
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HIGHData: must meet 2 categories
• • •
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ModerateRisk: of Morbidity from...
• • •
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HIGHRisk: of Morbidity from...
• • •
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MODERATE Level of MDM was Required
• • •
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HIGH Level of MDM was Required
• • •
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MedicalDecisionMakingGuide
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MDM-Time Equivalent
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XXXXXXXXXXXXXXDoNotUseBelowXXXXXXXXXXXXXXXXXXXXXXXXX
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