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    Wound

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    karlalau2024

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    © All Rights Reserved
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    Wound

    Uploaded by

    karlalau2024
    1 views4 pages

    Copyright

    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    1 views4 pages

    Wound

    Uploaded by

    karlalau2024

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    You are on page 1of 4

    Well Woman Visit

    Applies to all well woman visits, besides EWC (Every Woman Count)

    Templates:
    Check with your assigned provider which templates they are using.

    Roles and Responsibilities


    Intake:
    Previsit
    Take vitals
    Update and document patient data
    Provide educational forms as appropriate
    Discharge:
    Assist pap smears/wet mount
    Execute treatment plan
    Collect copay as needed
    Claim

    Intake:
    Documentation

    - 1st line: Well Woman Exam


    - 2nd line: patient complaints (if any)
    HPI:

    - Update and verify these sections


    - Pay attention to drop down options for ‘problems during intercourse’ and
    ‘current birth control method’: may select more than one option (see
    image below)
    - Verify and update each of these sections

    - PHQ2 screening, ask PHQ9 if patient scores 1 point


    Directly to PHQ9 if patient is diagnosed with psych issues
    Or last PHQ9 was positive
    - Life Style : Exercise and Diet

    If patient is in menopause, ask if she is experiencing any postmenopausal bleeding


    (PMB)
    Discharge:
    1) A. Specimen
    2) a. Confirm specimens are labelled with
    patient identifier (name and DOB)
    3) b. Place specimens in the correct
    laboratory bag (Sun lab or Quest)
    4) c. Include order form in bag
    5) i. include info (LMP, previous
    pap, previous bx) in pap
    smear order
    6) Wet Mount, Chlamydia
    and Gonorrhoea tests are
    sometimes ordered for
    patient
    Make sure they are in lab
    order form
    Preventive Medicine:
    *Med Safety:
    Medication Containers brought in today. .
    Possible barriers to medication adherence addressed and discussed. .
    Patient verbalised understanding regarding information given
    Screening : pap at three years :
    Mammogram:
    self-care/management. Violence Prevention:
    Neglect and abuse observed?

    - Verify and update each of these sections

    B. CPT code for procedures done during visit


    a. Q0091: screening pap smear
    b. 87624: HPV high risk types
    c. 88142: Cytopath, thin layers
    d. 77067: mammogram screen
    e. 81025: pregnancy test
    f. 87210: wet mount
    C. Imaging orders
    a. Consider patient’s insurance on whether order needs to apply
    b. Mammogram
    i. Pay attention to whether it is screening or diagnostic
    ii. If patient has implants or any surgery history, order must be diagnostic
    (change order Assign to : Referral Coordinator)
    Iii. if any STAT/ URGENT order or referral
    contact referral Coordinator immediately

    D. BMI measurement needs for this is one of the most important ways to
    improve your health and protect against disease.

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