|
StartAssessment5
|
|
|
5Assessment
|
5Assessment #
|
|
5Impression w/ icd10.MustSelect1
• • •
|
5Impression Freetext
|
|
5Impression.DDX
• • •
|
5ImpressionDDX.FreeText
|
|
5problem location
• • •
|
5ImpressionLocationFreetext
|
|
5 Enter Counseling Macro here
|
|
|
1PIC1.2
|
1PIC1.1
|
|
1PIC1.3
|
1PIC1.4
|
|
1PIC1.5
|
1Procedure Consent
|
|
5.Pics On/Off
|
1.Problem Status - Improved / Worse?
• • •
|
|
5OtherTreatment
• • •
|
1Other.ifTxDeferred,SpecifyY.
|
|
1PLAN: REMOVAL
|
1# of ML Lidocaine
|
|
1.removal- Malignant
|
1.removal - B9
|
|
1.removal-Malig- Trunk,Ext
|
1SIZE of lesion : Malig- Trunk,Extremity
• • •
|
|
1.removal.Malig- Hand,Foot,Neck.
|
1SIZE of lesion : Malig- Hand,Foot,Neck.
• • •
|
|
1.removal-Malig- Face, mm
|
1SIZE of lesion : Malig- Face, mm
• • •
|
|
1.removal- B9- Trunk-Extremity
|
1-B9 Size-Trunk-Extremity
• • •
|
|
1.removal- B9- Hand,Foot,Neck.
|
1-B9-Size- Hand,Foot,Neck.
• • •
|
|
1.removal- B9- face- mm
|
1-B9-Size-face- mm
• • •
|
|
1Hemostasis + closing
• • •
|
1.removal Addl notes
|
|
5CRYO
|
|
|
5CRYO- AK
|
5CRYO - AK & Qty
• • •
|
|
5CRYO/PLASM. B9
|
5CRYO/PLASMA-B9 Lesion Type & Qty
• • •
|
|
5CRYO/PLASMA. SkinTag
|
5CRYO/PLASMA Skin Tag - #
• • •
|
|
5PlasmaPen ProcedureStatement
|
5CRYO # of Frz / Thaw Cycles
• • •
|
|
1# of ML Lidocaine
|
5Treatment #
|
|
5CRYO- ADDL NOTES
|
|
|
1DESTRUCTION MALIGNANT LESION
|
|
|
1Destruction CRYO
|
1cryo#of_mL_Lido
|
|
1CRYO - Trunk, Arm, Legs
|
1SIZE of lesion : Trunk, Arms, Legs
• • •
|
|
1CRYO - Scalp, Neck, Hands, Feet
|
1SIZE of lesion : Scalp, Neck, Hands, Feet
• • •
|
|
1CRYO - Face, Ears, Eyelids, Nose, Lip
|
1SIZE of lesion : Face, Ears, Eyelids, Nose, Lip
• • •
|
|
1# of Frz / Thaw Cycles
• • •
|
|
|
1Cryo - BCC
|
1cryo - BCC - Loc
• • •
|
|
1Cryo - SCC
|
1cryo - SCC - Loc
• • •
|
|
1Cryo - SCCIS
|
1cryo - SCCIS - Loc
• • •
|
|
4.1DestructionTreatment #
|
1destructionCRYO- ADDL NOTES
|
|
1DNA WOUND SWAB
|
1DNA Addl Notes
|
|
1OTC Tx Regimen
|
1OTC Topicals
• • •
|
|
1OTC Tx Addl Notes
|
|
|
1PRESCRIPTION
|
1Prescriptions
• • •
|
|
1Prescription Addl Notes
|
|
|
1.5FU INJECTION
|
1Treatment #
|
|
1Lot #:
|
1Consent Obtained?
|
|
1LESION TYPE
• • •
|
1QTY of MLs
|
|
|
1.5FU Addl Notes
|
|
1DermTech Adhesive Biopsy
|
1DermTech Addl Notes
|
|
1.Kenalog Injection
|
1Consent obtained?
|
|
1. # of lesions/ IM injections
|
1Kenalog.IM or LesionType
• • •
|
|
1INJECTION SITE
• • •
|
1Kenalog ML/volume
• • •
|
|
1Kenalog Type/ concentration
• • •
|
1Qty of lido mixed?
• • •
|
|
1Total volume inj w/ lido
• • •
|
1Lot #
|
|
1Expiration Date
/
|
|
|
1Kenalog Addl Notes
|
|
|
1 Debridement
|
1Size: L mm x W mm x D mm
|
|
1Blade used
• • •
|
1Drainage Type&Amount
• • •
|
|
1Dressing type
• • •
|
1Debridement Addl Notes
|
|
1Dressing Change Performed
|
|
|
1Dressing type
• • •
|
1Dressing Change Addl Notes
|
|
1Dressing Change Regimen
|
1DressingRegimen
• • •
|
|
1Dressing type
• • •
|
1Dressing Regimen Addl Notes
|
|
1PLAN: I&D or FreeText___
|
1WritePlanNameHere_
|
|
1.FreeTxt Plan Details
|
|
|
1.FreetxtPlanDetails
• • •
|
1.Lesion Type
• • •
|
|
|
1.PlnFreeTxt.AddlNotes
|
|
StartAssessment6
|
|
|
6Assessment
|
6Assessment #
|
|
6Impression w/ icd10.MustSelect1
• • •
|
6Impression Freetext
|
|
6Impression.DDX
• • •
|
6ImpressionDDX.FreeText
|
|
6problem location
• • •
|
6ImpressionLocationFreetext
|
|
6Enter Counseling Macro here
|
|
|
6PIC2.1
|
6PIC2.2
|
|
6PIC2.3
|
6PIC2.4
|
|
6PIC2.5
|
6Procedure Consent
|
|
6Pics On/Off
|
6Problem Status - Improved / Worse?
• • •
|
|
6OtherTreatment
• • •
|
6Other.ifTxDeferred,SpecifyY.
|
|
6PLAN: REMOVAL
|
6#of_mL_Lido
|
|
6removal- Malignant
|
6removal - B9
|
|
6removal-Malig- Trunk,Extremity
|
6SIZE of lesion : Malig- Trunk,Extremity
• • •
|
|
6removal-Malig- Hand,Foot,Neck.
|
6SIZE of lesion : Malig- Hand,Foot,Neck.
• • •
|
|
6removal-Malig- Face, mm
|
6SIZE of lesion : Malig- Face, mm
• • •
|
|
6removal- B9- Trunk-Extremity
|
6size- B9 -Trunk-Extremity
• • •
|
|
6removal- B9- Hand,Foot,Neck.
|
6size- B9- Hand,Foot,Neck.
• • •
|
|
6removal- B9- face- mm
|
2.size- B9- face- mm
• • •
|
|
2Hemostasis + closing
• • •
|
2.removal Addl notes
|
|
6CRYO
|
|
|
6CRYO- AK
|
6CRYO - AK & Qty
• • •
|
|
6CRYO/PLASM. B9
|
6CRYO/PLASMA-B9 Lesion Type & Qty
• • •
|
|
6CRYO/PLASMA. SkinTag
|
6CRYO/PLASMA Skin Tag - #
• • •
|
|
6PlasmaPen ProcedureStatement
|
6CRYO # of Frz / Thaw Cycles
• • •
|
|
6LIDO # of ML
|
6Treatment #
|
|
6CRYO- ADDL NOTES
|
|
|
6DESTRUCTION MALIGNANT LESION
|
|
|
2Destruction CRYO
|
6cryo#of_mL_Lido
|
|
2CRYO - Trunk, Arm, Legs
|
2SIZE of lesion : Trunk, Arms, Legs
• • •
|
|
2CRYO - Scalp, Neck, Hands, Feet
|
2SIZE of lesion : Scalp, Neck, Hands, Feet
• • •
|
|
2CRYO - Face, Ears, Eyelids, Nose, Lip
|
2SIZE of lesion : Face, Ears, Eyelids, Nose, Lip
• • •
|
|
2# of Frz / Thaw Cycles
• • •
|
|
|
2Cryo - BCC
|
2cryo - BCC - Loc
• • •
|
|
2Cryo - SCC
|
2cryo - SCC - Loc
• • •
|
|
2Cryo - SCCIS
|
2cryo - SCCIS - Loc
• • •
|
|
2.DestructionTreatment #
|
2destructionCRYO- ADDL NOTES
|
|
2DNA WOUND SWAB
|
2DNA Addl Notes
|
|
2Debridement
|
2Size: L mm x W mm x D mm
|
|
2Blade used
• • •
|
2Drainage Type&Amount
• • •
|
|
2Dressing type
• • •
|
2DebridementAddl Notes
|
|
2Dressing Change Performed
|
2Dressing change location
• • •
|
|
2Dressing type
• • •
|
2Dressing Change Addl Notes
|
|
2Dressing Change Regimen
|
2Regimens
• • •
|
|
2Dressing type
• • •
|
2DressigRegimen Addl Notes
|
|
2OTC Tx Regimen
|
2OTC Topicals
• • •
|
|
2OTC tx Addl Notes
|
|
|
2PRESCRIPTION
|
2Prescriptions
• • •
|
|
2RX Addl Notes
|
|
|
2.5FU INJECTION
|
2Treatment #
|
|
2Lot #:
|
2Consent Obtained?
|
|
2LESION TYPE
• • •
|
2QTY of MLs
|
|
|
2.5FU Addl Notes
|
|
2DermTech Adhesive Biopsy
|
2DermTech Addl Notes
|
|
2Intralesional Kenalog Injection
|
2Consent obtained?
|
|
2. # of lesions injected
|
2Kenalog Lesion Type
• • •
|
|
2INJECTION SITE
• • •
|
2Kenalog ML/volume
• • •
|
|
2Kenalog Type/ concentration
• • •
|
2Qty of lido mixed?
• • •
|
|
2Total volume inj w/ lido
• • •
|
2Lot #
|
|
2Expiration Date
/
|
|
|
2Kenalog Addl Notes
|
|
|
2PLAN: I&D or FreeText___
|
2WritePlanNameHere_
|
|
2.FreetxtPlanDetails
• • •
|
2.FreeTxt Plan Details
|
|
2.Lesion Type
• • •
|
2.PlanFreeTxt_ LocationSame
|
|
2.PlnFreeTxt.AddlNotes
|
|
|
StartAssessment7
|
|
|
7Assessment
|
7Assessment #
|
|
7Impression w/ icd10.MustSelect1
• • •
|
7Impression Freetext
|
|
3Impression.DDX
• • •
|
3ImpressionDDX.FreeText
|
|
7problem location
• • •
|
3ImpressionLocationFreetext
|
|
3 Enter Counseling Macro here
|
|
|
3PIC3.1
|
3PIC3.2
|
|
3PIC3.3
|
3PIC3.4
|
|
3PIC3.5
|
3Procedure Consent
|
|
3.Pics On/Off
|
3.Problem Status - Improved / Worse?
• • •
|
|
7OtherTreatment
• • •
|
3Other.ifTxDeferred,SpecifyY.
|
|
3PLAN: REMOVAL
|
3.Shave#of_mL_Lido
|
|
3.removal- Malignant
|
3.removal - B9
|
|
3.removal-Malig- Trunk,Extremity
|
3.size of lesion : Malig- Trunk,Extremity
• • •
|
|
3.removal-Malig- Hand,Foot,Neck.
|
3.size of lesion : Malig- Hand,Foot,Neck.
• • •
|
|
3.removal-Malig- Face, mm
|
3.size of lesion : Malig- Face, mm
• • •
|
|
3.removal- B9- Trunk-Extremity
|
3.removal- B9 -Trunk-Extremity
• • •
|
|
3.removal- B9- Hand,Foot,Neck.
|
3.removal- B9- Hand,Foot,Neck.
• • •
|
|
3.removal- B9- face- mm
|
3.removal- B9- face- mm
• • •
|
|
3Hemostasis + closing
• • •
|
3.removal Addl notes
|
|
7CRYO
|
|
|
7CRYO- AK
|
7CRYO - AK & Qty
• • •
|
|
7CRYO/PLASM. B9
|
7CRYO/PLASMA-B9 Lesion Type & Qty
• • •
|
|
7CRYO/PLASMA. SkinTag
|
7CRYO/PLASMA Skin Tag - #
• • •
|
|
7PlasmaPen ProcedureStatement
|
7CRYO # of Frz / Thaw Cycles
• • •
|
|
7LIDO # of ML
|
7Treatment #
|
|
7CRYO- ADDL NOTES
|
|
|
3DESTRUCTION MALIGNANT LESION
|
|
|
3Destruction CRYO
|
3cryo#of_mL_Lido
|
|
3CRYO - Trunk, Arm, Legs
|
3SIZE of lesion : Trunk, Arms, Legs
• • •
|
|
3CRYO - Scalp, Neck, Hands, Feet
|
3SIZE of lesion : Scalp, Neck, Hands, Feet
• • •
|
|
3CRYO - Face, Ears, Eyelids, Nose, Lip
|
3SIZE of lesion : Face, Ears, Eyelids, Nose, Lip
• • •
|
|
3# of Frz / Thaw Cycles
• • •
|
|
|
3Cryo - BCC
|
3cryo - BCC - Loc
• • •
|
|
3Cryo - SCC
|
3cryo - SCC - Loc
• • •
|
|
3Cryo - SCCIS
|
3cryo - SCCIS - Loc
• • •
|
|
3.DestructionTreatment #
|
3destructionCRYO- ADDL NOTES
|
|
3DNA WOUND SWAB
|
3DNA Addl Notes
|
|
3 Debridement
|
3Size: L mm x W mm x D mm
|
|
3Blade used
• • •
|
3Drainage Type&Amount
• • •
|
|
3Dressing type
• • •
|
3Debridement Addl Notes
|
|
3Dressing Change Performed
|
3Dressing type
• • •
|
|
3Dressing Chng Addl Notes
|
|
|
3Dressing Change Regimen
|
3Regimens
• • •
|
|
3Dressing type
• • •
|
3Dressing Regimn Addl Notes
|
|
3OTC Tx Regimen
|
3OTC Topicals
• • •
|
|
3OTC tx Addl Notes
|
|
|
3PRESCRIPTION
|
3Prescriptions
• • •
|
|
3RX Addl Notes
|
|
|
3.5FU INJECTION
|
3Treatment #
|
|
3Lot #:
|
3Consent Obtained?
|
|
3LESION TYPE
• • •
|
3QTY of MLs
|
|
|
3.5FU Addl Notes
|
|
3DermTech Adhesive Biopsy
|
3DermTech Addl Notes
|
|
3Intralesional Kenalog Injection
|
3Consent obtained?
|
|
3. # of lesions injected
|
3Kenalog Lesion Type
• • •
|
|
3INJECTION SITE
• • •
|
3Kenalog ML/volume
• • •
|
|
3Kenalog Type/ concentration
• • •
|
3Qty of lido mixed?
• • •
|
|
3Total volume inj w/ lido
• • •
|
3Lot #
|
|
3Expiration Date
/
|
|
|
3Kenalog Addl Notes
|
|
|
3PLAN: I&D or FreeText___
|
3WritePlanNameHere_
|
|
3.FreetxtPlanDetails
• • •
|
3.FreeTxt Plan Details
|
|
3.Lesion Type
• • •
|
|
|
3.PlnFreeTxt.AddlNotes
|
|
|
StartAssessment8
|
|
|
8Assessment
|
8Assessment #
|
|
8Impression w/ icd10.MustSelect1
• • •
|
8Impression Freetext
|
|
4Impression.DDX
• • •
|
4ImpressionDDX.FreeText
|
|
8problem location
• • •
|
4ImpressionLocationFreetext
|
|
4 Enter Counseling Macro here
|
|
|
4PIC4.1
|
4PIC4.2
|
|
4PIC4.3
|
4PIC4.4
|
|
4PIC4.5
|
4Procedure Consent
|
|
4.Pics On/Off
|
4.Problem Status Improved / Worse?
• • •
|
|
4OtherTreatment
• • •
|
4Other.ifTxDeferred,SpecifyY.
|
|
4PLAN: REMOVAL
|
4removal#of_mL_Lido
|
|
4.Removal- Malignant
|
4.removal - B9
|
|
4.removal-Malig- Trunk,Extremity
|
4SIZE 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.
• • •
|
|
4Removal- B9- face- mm
|
4.size- B9- face- mm
• • •
|
|
4Hemostasis + closing
• • •
|
4Removal Addl notes
|
|
8CRYO
|
|
|
8CRYO- AK
|
8CRYO - AK & Qty
• • •
|
|
8CRYO/PLASM. B9
|
8CRYO/PLASMA-B9 Lesion Type & Qty
• • •
|
|
8CRYO/PLASMA. SkinTag
|
8CRYO/PLASMA Skin Tag - #
• • •
|
|
8PlasmaPen ProcedureStatement
|
8CRYO # of Frz / Thaw Cycles
• • •
|
|
8LIDO # of ML
|
8Treatment #
|
|
8CRYO- ADDL NOTES
|
|
|
4DESTRUCTION MALIGNANT LESION
|
|
|
4Destruction CRYO
|
8cryo#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
|
|
4 Debridement
|
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
|
4Regimens
• • •
|
|
4Dressing type
• • •
|
4Dressing Regimn Addl Notes
|
|
4OTC Tx Regimen
|
4OTC Topicals
• • •
|
|
4OTC reg Addl Notes
|
|
|
4PRESCRIPTION
|
4Prescriptions
• • •
|
|
4RX 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
|
4Consent obtained?
|
|
4. # of lesions injected
|
4Kenalog Lesion Type
• • •
|
|
4INJECTION SITE
• • •
|
4Kenalog ML/volume
• • •
|
|
4Kenalog Type/ concentration
• • •
|
4Qty of lido mixed?
• • •
|
|
4Total volume inj w/ lido
• • •
|
4Lot #
|
|
4Expiration Date
/
|
|
|
4Kenalog Addl Notes
|
|
|
4PLAN: I&D or FreeText___
|
4WritePlanNameHere_
|
|
4.FreetxtPlanDetails
• • •
|
4.FreeTxt Plan Details
|
|
4.Lesion Type
• • •
|
|
|
4.PlnFreeTxt.AddlNotes
|
|
|
XXXXXXXXXXXX Start Follow Up XXXXXXXX
|
|
|
Instruction | Pt Education | Addl Pics
|
CRYO AFTERCARE SHEET
|
|
Discussed ABCDEs (ON)
|
Education Comments
|
|
Education
|
Education Comments
|
|
Education
|
Education Comments
|
|
A: Visit/Aftercare Discussed With Who?
|
B: Write First Name Here
|
|
C: <--CommForm2Same Person?
|
D: Other Indv Name/Addl Notes
|
|
E: Enter Fax/Email 2 send Note/Orders
|
|
|
|
|
|
Communication Form/ Visit Summary
|
BlankRecordsRelease
|
|
addl pic1
|
addl pic2
|
|
addl pic3
|
addl pic4
|
|
2Follow up:
|
2Follow UP:
• • •
|
|
2Follow Up Priority Lvl
• • •
|
Reason for follow up
• • •
|
|
Est. FU Time.Select1. A=15.B=30.C=45.D=60. Required
|
|
|
Req Est. FU Visit Time Needed
• • •
|
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FU4Impression5
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FU4Impression5freetext
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FU4Impression5.Location
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2.5status
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FU4Impression6
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FU4Impression6freetext
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FU4Impression6.Location
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2.6status
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FU4Impression7
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FU4Impression7freetext
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FU4Impression7.Location
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2.7status
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FU4Impression8
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FU4Impression8freetext
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FU4Impression8.Location
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2.8status
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FU Addl Notes
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2.Turn OFF Pics b4 Faxing
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Nxt Appt Appropriate 4 Telehealth?
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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 performed5
• • •
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Quantity Performed5
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Procedure performed6
• • •
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Quantity Performed6
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Procedure performed7
• • •
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Quantity Performed7
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Procedure performed8
• • •
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Quantity Performed8
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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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2Visit 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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A HIGH Level of MDM was Required
• • •
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MedicalDecisionMakingGuide
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MDM-Time Equivalent
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Do not use below_________________________
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• • •
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