|
Freehand
|
|
|
In-Office Procedure Done
|
|
|
1) Click if In-Office Procedure Done
|
|
|
2) Click if Consent Filled Out and Signed**
|
|
|
A) Choose Anesthetic Block (if Applicable)
|
|
|
3) Digital Block Done
|
-or- Proximal Block Done
|
|
Siegel Marc/Lido Digital Block (3cc)
|
Total Marc/Lido Amount?
|
|
Baker/Zuri Digital Block (3cc)
|
Proximal Block Location?*
• • •
|
|
B) Choose Office Procedure
|
|
|
1) I & D Abscess Toe (10061)
|
|
|
I & D Abscess Toe (10061) [Choose Toe]
|
|
|
L Great Toe
|
Which Border
|
|
R Great Toe
|
Which Border
|
|
L 2nd Toe
|
Which Border
|
|
R 2nd Toe
|
Which Border
|
|
L 3rd Toe
|
Which Border
|
|
R 3rd Toe
|
Which Border
|
|
L 4th Toe
|
Which Border
|
|
R 4th Toe
|
Which Border
|
|
L 5th Toe
|
Which Border
|
|
R 5th Toe
|
Which Border
|
|
.
|
|
|
Soaking Instructions
|
|
|
Soaking Only Instructions Given
|
|
|
Amerigel Instructions Given
|
|
|
Soaking and Antibiotic Ointment Instructions Given
|
|
|
-------------------------------------------------------------------------------------
|
|
|
|
|
|
2) I and D Abscess Foot/Leg (10061)
|
|
|
I & D Abscess Foot or Leg (10061)
|
|
|
Foot
|
-or- Leg
|
|
Which part of the LEFT foot? (the left "____")
|
-or- Which part of the RIGHT foot? (the right "____")
|
|
Which Part of Left Leg?
• • •
|
Which Part of Right Leg?
• • •
|
|
-------------------------------------------------------------------------------------
|
|
|
|
|
|
3) Nail Avulsion without Matrixectomy (11730)
|
|
|
Nail Avulsion without Matrixectomy (11730) [Choose Toe]
|
|
|
L Great Toe
|
Which Border
|
|
R Great Toe
|
Which Border
|
|
L 2nd Toe
|
Which Border
|
|
R 2nd Toe
|
Which Border
|
|
L 3rd Toe
|
Which Border
|
|
R 3rd Toe
|
Which Border
|
|
L 4th Toe
|
Which Border
|
|
R 4th Toe
|
Which Border
|
|
L 5th Toe
|
Which Border
|
|
R 5th Toe
|
Which Border
|
|
.
|
|
|
Soaking Instructions
|
|
|
Soaking Only Instructions Given
|
|
|
Amerigel Instructions Given
|
|
|
Soaking and Antibiotic Ointment Instructions Given
|
|
|
-------------------------------------------------------------------------------------
|
|
|
|
|
|
4) Nail Avulsion WITH Matrixectomy (11750)
|
|
|
Nail Avulsion with Matrixectomy (11750) [Choose Toe]
|
|
|
L Great Toe
|
Which Border
|
|
R Great Toe
|
Which Border
|
|
L 2nd Toe
|
Which Border
|
|
R 2nd Toe
|
Which Border
|
|
L 3rd Toe
|
Which Border
|
|
R 3rd Toe
|
Which Border
|
|
L 4th Toe
|
Which Border
|
|
R 4th Toe
|
Which Border
|
|
L 5th Toe
|
Which Border
|
|
R 5th Toe
|
Which Border
|
|
Choose if partial or total nail avulsion
|
|
|
**Partial nail WITH Phenol Description**
|
**Partial Nail WITH Sodium Hydroxide Description**
|
|
**Total Nail WITH Phenol Description**
|
**Total Nail WITH Sodium Hydroxide Description**
|
|
Soaking Instructions
|
|
|
Soaking Only Instructions Given
|
|
|
Amerigel Instructions Given
|
|
|
Soaking and Antibiotic Ointment Instructions Given
|
|
|
-------------------------------------------------------------------------------------
|
|
|
|
|
|
Other Office Procedures
|
|
|
Removal of FB, Simple (10120)
|
Removal of FB, Complex (10121)
|
|
Removal of Foreign Body
|
|
|
Removal of Foreign Body
|
|
|
L Removal of FB, Simple, No Anesthesia
|
R Removal of FB, Simple, No Anesthesia
|
|
L Removal of FB, Simple, WITH Anesthesia
|
R Removal of FB, Simple, WITH Anesthesia
|
|
-------------------------------------------------------------------------------------
|
|
|
|
|
|
L Removal of FB, Complex
|
R Removal of FB, Complex
|
|
L Removal of Deep Foreign Body
• • •
|
R Removal of Deep Foreign Body
• • •
|
|
-------------------------------------------------------------------------------------
|
|
|
|
|
|
Repair of Laceration
|
|
|
Repair of Laceration
|
|
|
Repair of Deep Lac Location
• • •
|
Dimensions of laceration (__ x__mm)?*
|
|
-------------------------------------------------------------------------------------
|
|
|
|
|
|
Biopsy of Soft Tissue or Nail
|
|
|
a) Nail Unit Biopsy (11755)
|
|
|
Nail Unit Biopsy (11755) [Choose Nail]
|
|
|
L Great Toe
|
Which Border
|
|
R Great Toe
|
Which Border
|
|
L 2nd Toe
|
Which Border
|
|
R 2nd Toe
|
Which Border
|
|
L 3rd Toe
|
Which Border
|
|
R 3rd Toe
|
Which Border
|
|
L 4th Toe
|
Which Border
|
|
R 4th Toe
|
Which Border
|
|
L 5th Toe
|
Which Border
|
|
R 5th Toe
|
Which Border
|
|
.
|
|
|
-------------------------------------------------------------------------------------
|
|
|
|
|
|
b) Shave Biopsy (11300-11306)
|
|
|
Shave Biopsy (11300-11306)
|
|
|
Foot Lesion
|
-or- Leg Lesion
|
|
Choose appropriate size
|
|
|
<0.5cm Width (Foot)
|
-or- 0.5-1cm Width (Foot)
|
|
Left Foot 0.5-1cm (No Anesthesia)
|
Right Foot 0.5-1cm (No Anesthesia)
|
|
Shave Biopsy Location ("The left ____ was prepped...")
|
Shave Biopsy Location ("The right ____ was prepped...")
|
|
-------------------------------------------------------------------------------------
|
|
|
-------------------------------------------------------------------------------------
|
|
|
Left Foot 0.5-1cm (with anesthesia)
|
Right Foot 0.5-1cm (with anesthesia)
|
|
Shave Biopsy Location ("The left ____ was prepped...")
|
Shave Biopsy Location ("The right ____ was prepped...")
|
|
-------------------------------------------------------------------------------------
|
|
|
-------------------------------------------------------------------------------------
|
|
|
Left Foot <0.5 (No Anesthesia)
|
Right Foot <0.5cm (No Anesthesia)
|
|
Shave Biopsy Location ("The left ____ was prepped...")
|
Shave Biopsy Location ("The right ____ was prepped...")
|
|
-------------------------------------------------------------------------------------
|
|
|
-------------------------------------------------------------------------------------
|
|
|
Left Foot <0.5cm (with anesthesia)
|
Right Foot <0.5cm (with anesthesia)
|
|
Shave Biopsy Location ("The left ____ was prepped...")
|
Shave Biopsy Location ("The right ____ was prepped...")
|
|
Shave Biopsy Location
• • •
|
Shave Biopsy Location
• • •
|
|
-------------------------------------------------------------------------------------
|
|
|
-------------------------------------------------------------------------------------
|
|
|
<0.5cm Width (Leg)
|
0.5-1cm Width (Leg)
|
|
L Leg 0.5-1cm (No Anesthesia)
|
R Leg 0.5-1cm (No Anesthesia)
|
|
Shave Biopsy Location
• • •
|
Shave Biopsy Location
• • •
|
|
L Leg 0.5-1cm
|
R Leg 0.5-1cm
|
|
Shave Biopsy Location
• • •
|
Shave Biopsy Location
• • •
|
|
L Leg <0.5cm (No Anesthesia)
|
R Leg <0.5cm (No Anesthesia)
|
|
Shave Biopsy Location
• • •
|
Shave Biopsy Location
• • •
|
|
L Leg <0.5cm
|
R Leg <0.5cm
|
|
Shave Biopsy Location
• • •
|
Shave Biopsy Location
• • •
|
|
Punch Biopsy
|
|
|
Punch Biopsy withOUT Closure
|
Punch Biopsy WITH Closure
|
|
Left Foot/Leg
|
Right Foot/Leg
|
|
Punch Biopsy w/out Closure (Location)
• • •
|
Punch Size*
|
|
Punch Biopsy w/out Closure (Location)
• • •
|
Punch Size*
|
|
Left Foot/Leg
|
Right Foot/Leg
|
|
Punch Biopsy WITH Closure (Location)
• • •
|
Punch Size*
|
|
Punch Biopsy WITH Closure (Location)
• • •
|
Punch Size*
|
|
-------------------------------------------------------------------------------------
|
|
|
-------------------------------------------------------------------------------------
|
|
|
Weightbearing and Activity
|
|
|
WeightBearing Status
|
Excusal Note Given
|
|
Activity Level
• • •
|
|
|
If symptoms fail to improve by next visit
• • •
|
|
|
Other
|
|
|
Other In-Office Procedure Not Shown
|
|
|
Other In-Office Procedure Not Show
|
|
|
When to Return?
|
|
|
How many months?
|
2 months
|
|
How many weeks?
|
1 month
|
|
How many days?
|
3 weeks
|
|
|
2 weeks
|
|
|
1 week
|
|
|
PRN
|
