Benefits from our library of a specialty-specific procedure or encounter templates

An Epidural Steroid Injection is a procedure used to relieve pain emanating from a person’s back, neck, or limbs on either right or left sidearms and/or legs. The procedure is considered minimally invasive. The injection is designed to relieve nerve pain caused by a pinched nerve or inflammation caused by a wide range of activities or genetics.

At a glance, the provider can select from a library of specialty-specific procedure or encounter template to absorb, confirm, and begin to document. The documentation can be a new encounter or add to a patient’s previous visit. The template is laid out to be fast, comprehensive, efficient and has a logical workflow.

The patient encounter Navigation bar allows for a one-click launch into the desired template based on patient visit reason. The provider’s tailored template library appears and the selection will drive the encounter.

The Elements of the procedure are clearly displayed, and specific annotation can be captured, and result identified. Each line item opens a specific remark which can be a free-form notation. Each template can be amended or adjusted as necessary by the provider which lends to PrognoCIS flexible documentation benefit to the individual provider.

The Cervical Epidural Steroid Injection captures the procedure as documenting and PrognoCIS is building a high quality complete comprehensive provider note. This note includes but not limited to information such as Pre and Post-Operative diagnosis, procedure title with elements defined as level, anesthesia, injection number, risk and benefit explained with written consent. This detailed level of documentation is clearly and professionally expressed for the recipient of medical note and any annotation drawings to extenuate the patient identified location and pain scale.

Thoracic pain can be a sudden onset condition brought on by a traumatic experience or can be a painful condition because of years of bad posture. Patients can experience different levels of pain. Whether the pain is minor to severely debilitating. Pain relief is the objective desired to begin moving around freely with ease of pain and return to the quality of life. Treatment options will be based on the level of pain, daily activity lifestyle, gender, and age to identify a few defining criteria. How and what brought on the pain and the reason for the pain to create an appropriate care path for this specific diagnosis.

Documenting the patient encounter can be unique and specific. The History of Present Illness (HPI) will be identified as back pain, and specifically middle of the back known as the Thoracic Region between the neck and abdomen. Many thoracic pain conditions are derived from a herniated disc. Herniated discs can be caused by trauma or a degenerative disease. While the herniated disc is not typically painful, the matter that is leaking from the disc can cause radicular pain due to the inflammation, irritation of nerves nearby and pinches the pain point.
Radiofrequency Ablation commonly referred to as “RFA”. Pain Management Clinics have a wide variety of treatment options available to their patients to alleviate pain. Sometimes an injection or series of steroid injections as prescribed as a treatment plan can be beneficial. Other times, a pain management doctor might suggest a minimally invasive procedure known as RFA that uses radio waves to apply heat directly to a small nerve tissue to reduce the pronounced pain signals.

Obviously, there is no pain management treatment guaranteed procedure. Each patient has a unique sequence of events to bring on this pain. Therefore, a variety of treatment options are available to offer. Although the attending physician can make a diagnosis and prescribe a treatment plan, the plan comes with no pain relief guarantee. The treatment can be a one-time procedure or pre-planned period of treatment depending on the patient’s sense on expressed relief. The RFA has a success rate reported to be as high as 50% of patients report pain relief to be significant, which mirrors back the other percentage of patients reporting a continuation of experienced pain. Some successful treatments of RFA can last a duration of up to 2 years of relief before additional treatment prescription.

The Radiofrequency Ablation / RFA pain management template is designed for ease of use and deep dive pain documentation. The template is fast, flexible and can be easily amended during an examination or procedure. The template is rich and mature yet will allow the attending doctor to add as a permanent documentation point or just for the current patient procedure. The template has no hardcoding and allows each patient encounter to be unique.

Spinal Cord Stimulation (SCS) implanted neuromodulation device is also known as a “Pain Pacemaker” template is used to accurately document the reason for the device and any previous treatment options experienced and outcomes. The SCS is designed to electronically stimulate the nerves in the spinal cord. The SCS is considered by many as a more aggressive pain management treatment. The most common reason for prescribing an SCS is a back surgery performed and experience an unsuccessful surgery.

Pain management clinics offer pain relief treatments from minimally invasive to more invasive and aggressive options. The meticulous documentation presented in an SCS template is very detailed and thorough to include previous treatments and varying results with historical documentation. The patient education will describe to the patient and caregivers the pros and cons of the SCS procedure. This detailed description will include Medical use, procedure highlights, any adverse effects, and possible complications.

Epidural lysis of adhesions (LOA), is a pain management treatment to dissolve the build up of scar tissue with a class of medications to allow the patient to remain awake during the procedure and alleviate the pain points created by scar tissue. The scar tissue is created post back surgery and can become very painful and difficult for patients to move smoothly. Not all Epidural Adhesions are painful, however, then can become inflamed and attention needed. Although this is a spine surgery procedure, it is more minimally invasive than other treatment options.

The LOA template has unique documentation and the need is to be very concise as the patient treatment leading up to this procedure will require an educated patient to the risks and expected benefits involved with this procedure. There are risks but generally are snot seen as overwhelming in the classic definition. Infection, headaches created, adverse medical reactions and possible nerve damage. These are examples of risks identified in the LOA template to ensure patient awareness. Consensus has suggested the risks typically do not over weigh the benefits of pain relief and the renewed ambulatory patient experience.

Patients should expect the recovery time to be less than two weeks and return to daily life activities.