Procedures Tab

The Procedures tab allows the data abstractor to add, edit, and delete information about any procedures that were performed.

NOTE: Depending on the encounter status and the user’s role, the Procedures tab may be read only.

 

Procedure Tab Screenshot

 

To add a procedure

1.      Click Add Procedure.

2.      Use the following fields:

•      Laterality: Select the laterality, i.e., Left Eye, Right Eye, Both or Not Specified.

Add Procedure Laterality

•      CPT Code: Type the CPT code in the free text field.

•      Short / Long Description: Type the Name and Description in the free text fields.

Add Procedure Screenshot

3.      Click Add Procedure to add the procedure to the list, or Cancel to exit without retaining the settings.

4.      Click Save on the Encounter Actions menu to save, or Cancel to exit without saving.

To edit a procedure

1.      Click the corresponding Edit button

2.      Edit the fields as described above.

3.      Click Update to apply the revisions, or Cancel to exit without retaining the settings.

4.      Click Save on the Encounter Actions menu to save, or Cancel to exit without saving.

To remove a procedure

•      Click the corresponding Delete link, and then click OK when prompted to confirm.