Procedures

During an encounter between a provider and a patient, the provider may perform several activities. These activities are documented as procedures and they have several components:

1. CPT code - the Current Procedural Terminology code
2. CPT Description - a brief description of the CPT code
3. Charge - the amount your office charges for the procedure
4. Quantity - how many of the specific procedure will be charged

We will describe how you add procedures to an encounter, how to specify the procedure details, how to configure commonly used procedures and how to handle special situations.

The following sections of the procedure dialog are documented:

Before a procedure can be created an Encounter must created. In the image below there have been multiple procedures already created. Some of them have scrolled out of the table and can not be seen. Note: the procedure table is described in the Encounter chapter.

Procedure Details

In the Encounter dialog, shown above, is a table labeled Procedure. There are two ways to get to the Procedure Details dialog:

1. Next to this label is a New button. Selecting the New button will open the dialog and create a new procedure.
2. Using the mouse to double click on one of the procedures in the table will open the dialog.

The Procedure Details dialog is used for editing the details of a procedure, for deleting a procedure from the encounter and for creating additional procedures for the encounter. The Procedure Details dialog shown at the right has four sections. Each of the sections is described below.

Detail - Encounter section

At the very top of the dialog is a section called Encounter. This non-editable section, shown in gray above, is displayed for informational purposes only. It contains the basic three components of the encounter.

1. Patient - the name of the patient
2. Date - the date the encounter took place
3. Provider - the name of the provider of the encounter

Detail - Procedures section

The procedures table, shown at the right, is identical to the table found in the Encounter dialog. This table lists the current procedures identified for the encounter. When one of the procedures is selected with a single click of the mouse, the Procedure Detail section of the dialog fills with the detail information of the procedure.

Next to the procedure table are two buttons. These buttons will:

• New - open a edit dialog to create a new procedure
• Delete - will delete the currently selected procedure

Detail and Edit Selection section

This section of the dialog serves two purposes. First, it displays the detail information of the currently selected procedure in the procedure table (example shown above). In this example the 11402 procedure is selected. The second purpose of this section is to provide a means to getting to the edit dialogs of the procedure.

This section has three separate non-editable gray boxes. Selection of one of these boxes with the mouse will cause the appropriate edit dialog to appear. These edit dialogs and their detail are described in the next part of the documentation.(see index Procedures - Edit)

Detail - Notes and Control Buttons section

The Notes section of the dialog provides a place for notes to be added for the currently selected procedure. Selecting the non-editable Notes section with the mouse will open the procedure edit dialog to the notes section that allows you to enter a note.

This section of the dialog also has two buttons.

• PDFdoc button when selected will cause a PDF document to be created in the folder specified for "Reports" under preferences. This document will contain all of the detail information for the current procedure.
• Close button when selected will remove the Procedure Detail dialog.