PRE-PROCEDURE - SGNA



PRE-PROCEDURE

|Date |[pic] |

|Time of arrival |[pic] AM/PM |

History obtained from:

[pic]  Patient

[pic]  Spouse

[pic]  Parent

[pic]  Child

[pic]  Sibling

[pic]  Friend

[pic]  Significant other

[pic]  Other

Arrival mode

[pic]  Ambulatory

[pic]  Wheelchair

[pic]  Stretcher

Transportation

[pic]  Private

[pic]  Public

Arrived with:

[pic]   Alone

[pic]   Spouse

[pic]   Parent

[pic]   Child

[pic]   Sibling

[pic]   Friend

[pic]   Significant other

Discharge arrangements

[pic]   Driver

[pic]   In Lobby

[pic]   Need to call   [pic]

Signed generic post-op instructions

[pic]   Yes    [pic]   No

Date:    [pic]

Time:   [pic]

Reason for Procedure

(use ICD9 codes if automated)

[pic]   Abdominal pain

[pic]  Colorectal Cancer Screening

[pic]   Constipation

[pic]   Bleeding

[pic]   Dysphasia

[pic]   GERD/heartburn

[pic]   IBS

[pic]   Pain

[pic]   Other

Scheduled procedure

(pick multiple choices)

(link this to post procedure to link with actual procedure performed)

[pic]   EGD

    [pic]  Scheduled

    [pic]  Repeated

    [pic]  Unscheduled

[pic]   Endoscopic Ultrasound (EUS)

[pic]   Fine Needle Aspiration (FNA)

    [pic]  Scheduled

    [pic]  Repeated

[pic]  Flexible Sigmoidoscopy

    [pic]  Scheduled

    [pic]  Repeated

    [pic]  Unscheduled

[pic]   Colonoscopy

    [pic]  Scheduled

    [pic]  Repeated

    [pic]  Unscheduled

[pic]   ERCP

    [pic]  Scheduled

    [pic]  Repeated

    [pic]  Unscheduled

[pic]   Dilatation

    [pic]  Scheduled

    [pic]  Repeated

    [pic]  Emergency

[pic]   Manometry & Motility

    [pic]   Biliary

    [pic]  Esophageal

    [pic]  Rectal

    [pic]  Scheduled

    [pic]  Repeated

[pic]  24-hour pH

    [pic]  Scheduled

    [pic]  Repeated

[pic]  Capsule Endoscopy

    [pic]  Scheduled

    [pic]  Repeated

Pre-op contact

Date:    [pic]

Time:   [pic]

Person contacted  [pic]

    Relationship   [pic]

Person who initiated contact 

 [pic]

[pic]    No

Reason    [pic]

Procedure and patient verified

[pic]   Yes      [pic]   No

Reason:  [pic]

[pic]   Patient

[pic]   Physician

[pic]   Family/significant other

Patient issued:

[pic]   ID band

[pic]   Allergy ID band

[pic]   Mastectomy band

    [pic]  Not indicated

[pic]   Shunt band

    [pic]  Not indicated

Comments:

Pre-op teaching

Date:    [pic]

Time:   [pic]

Method

[pic]  Verbal

[pic]  Written

[pic]  Video

[pic]  Reason for procedure

[pic]  Verbalizes understanding

Individuals present for teaching

[pic]  Patient

[pic]  Spouse

[pic]  Parent

[pic]  Child

[pic]  Sibling

[pic]  Friend

[pic]  Significant other

Verbalized understanding of teaching content:

[pic]  Patient

[pic]  Spouse

[pic]  Parent

[pic]  Child

[pic]  Sibling

[pic]  Friend

[pic]  Significant other

Potential barriers to learning

[pic]  Anxiety level

[pic]  Cognitive ability

[pic]  Hearing

[pic]  Language

[pic]  Sight

Primary language

[pic]  English

[pic]  Spanish

Other   [pic]

[pic]   Translator utilized

People present for teaching (write in names)

[pic]

[pic]

Comments:

Review of medical history

Previous sedation analgesia problems

[pic]   Fainted

[pic]   Hyperexcitability

[pic]   Hypotension

[pic]   Persistent nausea

[pic]   Persistent vomiting

[pic]   Prolonged sedation

[pic]   Tachycardia

[pic]   Unstable blood pressure

[pic]   None

Patient allergies

[pic]   Latex

[pic]   Meds

    [pic]

    [pic]

    [pic]

    [pic]

[pic]   Food

[pic]   Dye (radiology)

[pic]   Other

    [pic]

    [pic]

    [pic]

    [pic]

Previous medical procedures

[pic]   Mastectomy

    [pic]  Right

    [pic]  Left

[pic]   Shunt

    [pic]  Right

    [pic]  Left

[pic]   Heart

    [pic]  Automatic internal cardiac defibrillator

    [pic]  Hypertension

    [pic]  Pacemaker

    [pic]  Valve replacement

    [pic]  Other  [pic]

[pic]   Lung

    [pic]  Asthma

    [pic]  Chronic obstructive pulmonary disease

   [pic]  Ostomy

[pic]   Liver/GI

    [pic]  Yes (Comments: free text field)

[pic]   Kidney/ GU

    [pic]  Yes (Comments: free text field)

[pic]   Airway (Mallampati classification per MD)

    [pic]  1-4

[pic]   Mouth opens adequately

    [pic]  Airway patent

[pic]   Neuro/seizures

    [pic]   Sleep apnea

Orthopedic

(flag intraprocedure grounding pad/pad placement)

[pic]   Appliance

    [pic]  Neck

    [pic]  Back

    [pic]  Upper extremity

        [pic]  Left

        [pic]  Right

    [pic]  Lower extremity

        [pic]  Left

        [pic]  Right

Significant family history

[pic]   Colorectal cancer

[pic]   Gardner syndrome

[pic]   Peutz-Jaegers Disease

Medications

[pic]   Anticoagulants

    [pic]  Aspirin

    [pic]  Coumadin

    [pic]  Plavix

    [pic]  Heparin

        [pic]   Date last taken

        [pic]   Time last taken

[pic]   Herbals

    [pic]  Date last taken

    [pic]  Time last taken

[pic]   MAO inhibitors

    [pic]  Date last taken

    [pic]  Time last taken

[pic]   Nonsteroidal anti-inflammatories

    [pic]  Date last taken

    [pic]  Time last taken

Exposure to:

[pic]   HIV

[pic]   Hepatitis A

[pic]   Hepatitis B

[pic]   Hepatitis C

[pic]   Sexually Transmitted Disease

[pic]   TB

[pic]   Other (free text)

Endocrine

[pic]   Insulin dependent/non-insulin dependent

[pic]   Last blood glucose [pic]

    [pic]  Date

    [pic]  Time

Substance use

[pic]   Alcohol

    [pic]  Amount (free text)

    [pic]  None

[pic]   Caffeine

    [pic]  Amount (free text)

    [pic]  None

[pic]   Drugs

    [pic]  Yes

            [pic]   History of (free text)

    [pic]  None

[pic]   Tobacco

    [pic]  Amount (free text)

    [pic]  Years

    [pic]  None

History of:

[pic]   Glaucoma

[pic]   Previous endoscopic procedures (list)

[pic]   Previous surgeries (list)

Comments: [pic]

Condition upon arrival

[pic]   American Society of Anesthetists (ASA) Scoring (per physician)

[pic]  1

[pic]  2

[pic]  3

[pic]  4

[pic]  5

Aldrete scoring per facility choice

[pic]   Activity

    [pic]  Able to move 4 extremities (2)

    [pic]  Able to move 2 extremities (1)

    [pic]  Able to move 0 extremities (0)

[pic]   Respiration

    [pic]  Deeply breaths, coughs freely (2)

    [pic]  Dyspnea or limited breathing (1)

    [pic]  Apneic (0)

[pic]   Circulation

    [pic]   Systolic BP +/- 20 mmHg pre-

procedure level (2)

    [pic]   Systolic BP +/- 20 mmHg to 50

mmHg pre-procedure level (1)

    [pic]   Systolic BP +/- 50 mmHg or more of

pre-procedure level (0)

[pic]   Consciousness

    [pic]  Fully awake (2)

    [pic]  Arises on calling (1)

    [pic]  Unresponsive (0)

[pic]   Color

    [pic]  Pink (2)

    [pic]  Pale, dusky, blotchy, jaundiced (1)

    [pic]  Cyanotic (0)

[pic]   Arrived in unit with oxygen at

______liters

    [pic]   How administered

            [pic]   Cannula

            [pic]   Mask

            [pic]   Tracheostomy

            [pic]   ET tube

Pain

[pic]   No

[pic]   Yes

    [pic]  Location

    [pic]  Duration

       [pic]   0-10

       [pic]   What 0-10 would be acceptable for patient?

    [pic]  Frequency

    [pic]  Symptoms relieved by

[pic]

    [pic]  Symptoms worsened by

[pic]

    [pic]  Description

            [pic]   Free text

Vital sign base line readings

[pic]   Blood pressure

[pic]   Pulse

[pic]   Respiratory rate

[pic]   O2 SAT

[pic]   Capnography (CO2)

[pic]   Temperature

Sedation plan

[pic]   Moderate

[pic]   Deep

[pic]   General

[pic]   Local

[pic]   Topical

General Assessment

Skin temperature

    [pic]  Warm

    [pic]  Cool

Skin status

[pic]   Dry

[pic]   Moist

[pic]   Intact

    [pic]  Yes

    [pic]  No

       [pic]   Body piercing

(free text to note location)

[pic]   Other

Follows command

[pic]   Yes

[pic]   No

Psychological state

[pic]   Agitated

[pic]   Anxious

[pic]   Cooperative

[pic]   Oriented

[pic]   Restless

[pic]   Tranquil

Weight

[pic]   Stated

[pic]   Actual

Height

[pic]   Stated

[pic]   Actual

Pregnant

[pic]   No

[pic]   Yes

    [pic]  Physician notified

[pic]   Date of last menstrual period

Respiratory Assessment

[pic]   Clear

[pic]   Congested

Abdominal assessment

[pic]   Distended

[pic]   Firm

[pic]   Flat

[pic]   Nontender

[pic]   Round

[pic]   Soft

[pic]   Tender

Intravenous (IV) access

[pic]   Extremity restriction

    [pic]  Left

    [pic]  Right

[pic]   New insertion

    [pic]   Time

[pic]   Name of person inserting/credentials

[pic]   Type of IV

(need option for more than 1 IV)

    [pic]  Size

    [pic]  Number of attempts

    [pic]  Patency

    [pic]  Peripheral

        [pic]   Angiocath

        [pic]   Butterfly

        [pic]   Other

    [pic]  Central

        [pic]   Triple lumen

        [pic]   Port

    [pic]  Site

        [pic]   L Hand

        [pic]   R Hand

        [pic]   L posterior forearm

        [pic]   R posterior forearm

        [pic]   L anterior forearm

        [pic]   R anterior of forearm

        [pic]   L anticubital space

        [pic]   R anticubital space

        [pic]   Other

    [pic]   Solution

        [pic]   D5/W

        [pic]   Normal saline

        [pic]   Lactated ringers

        [pic]   D5 1/2 NS

        [pic]   D5 1/4 NS

        [pic]   Packed red blood cells

        [pic]   Platelets

        [pic]   Fresh frozen plasma (FFP)

                  [pic]  Amount remaining

                  [pic]  Rate ordered

            [pic]   Other

[pic]   Arrived with IV access in place

    [pic]  Type of IV (need option for more than 1 IV)

    [pic]  Size

    [pic]  Number of attempts

    [pic]  Patency

    [pic]  Peripheral

            [pic]   Angiocath

            [pic]   Butterfly

            [pic]   Other

    [pic]  Central

            [pic]   Triple lumen

            [pic]   Port

    [pic]  Site

            [pic]   L Hand

            [pic]   R Hand

            [pic]   L posterior forearm

            [pic]   R posterior forearm

            [pic]   L anterior forearm

            [pic]   R anterior of forearm

            [pic]   L anticubital space

            [pic]   R antecubital space

            [pic]   Other

    [pic]  Solution

            [pic]   D5/W

            [pic]   Normal saline

            [pic]   Lactated ringers

            [pic]   D5 1/2 NS

            [pic]   D5 1/4 NS

            [pic]   Packed red blood cells

            [pic]   Platelets

            [pic]   Fresh frozen plasma (FFP)

                [pic]  Amount remaining

                [pic]  Rate ordered

            [pic]   Other

Oral Assessment

[pic]   Dentures

    [pic]  Yes

            [pic]   Removed

                [pic]  Upper

                [pic]  Lower

[pic]   Loose teeth

    [pic]  Yes

            [pic]   Location

[pic]   Tongue pierced

Risk/screen

[pic]   Abuse

    [pic]  Physical

    [pic]  Emotional

    [pic]  Mental

    [pic]  Verbal

    [pic]  Sexual

[pic]   Fall risk

[pic]   Nutrition

[pic]   Psychosocial

Comments:

Preparation for procedure

[pic]   NPO

    [pic]  Last solid food

        [pic]  Date

        [pic]  Time

    [pic]  Last liquids ingested

        [pic]  Date

        [pic]  Time

[pic]   Bowel prep

    [pic]  Type

        [pic]  PEG solution

        [pic]  Biscodyl tablets

        [pic]  Biscodyl suppositories

        [pic]  Fleets enema

        [pic]  Fleets oral

        [pic]  Citrate of Magnesia

        [pic]  Tap water enemas

        [pic]  Soap suds enemas

        [pic]  Visical

        [pic]  Other

    [pic]  Taken as instructed

        [pic]  Yes

        [pic]  No

            [pic]  Reason

    [pic]  Description of last stool

        [pic]  Consistency

            [pic]  Liquid

            [pic]  Semi-solid

            [pic]  Solid

        [pic]  Color

            [pic]  Clear

            [pic]  Yellow

            [pic]  Brown

        [pic]   Other

Review of lab results

[pic]   None ordered

[pic]   Within normal limits

[pic]   Physician notified of abnormality

[pic]   Not available

Advance directives

[pic]   Living will

    [pic]  Yes

    [pic]  No

[pic]   Additional information provided for

patient

[pic]   Patient does not wish more information

[pic]   Durable power of attorney for medical

affairs

Belongings removed

[pic]   Dentures

[pic]   Glasses

[pic]   Hearing aids

[pic]   Other

Disposition

[pic]   With patient

[pic]   With significant other

[pic]   Other

[pic]   Who completed assessment

(track staff with number system- unique identifier per facility policy)

Comments:

INTRA-PROCEDURE

Procedure and Patient re-verified

[pic]   Yes

    [pic]   Patient

    [pic]   Physician

    [pic]   Family/significant other

Verify allergies with patient

[pic]   yes

Verify sedation planned

[pic]   yes

Verify consent forms signed

[pic]   Procedure

[pic]   Sedation

[pic]   Observation (people in the room)

[pic]   Permission to discuss findings with [pic]

[pic]   Procedure Room number

[pic]   Time entered room

Personnel

[pic]   Nurse (drop down menu, free text)

[pic]   GI Tech (drop down menu, free text)

[pic]   Radiology Tech

(drop down menu, free text)

[pic]   Attending physician

(drop down menu, free text)

[pic]   Fellow (drop down menu, free text)

[pic]   Pathologist (drop down menu, free text)

[pic]   Resident (free text)

[pic]   Student (free text)

[pic]   Observer (free text)

Procedural information

Scopes

[pic]   Scope utilized (drop down box with all available scopes)

    [pic]   Not applicable

    [pic]   Scope ID number

[pic]   Time scope inserted in patient

[pic]   Time endoscopist reached cecum (only for colonoscopy)

[pic]   Time scope removed from patient

Events/Occurrences

[pic]   None

[pic]   Abdominal pressure applied

(link to colonoscopy/flex sigmoidoscopy procedures)

[pic]   Allergic reaction

[pic]   Anatomical variances

[pic]   Compromised airway

    [pic]   Required airway support

            [pic]   ET tube

            [pic]   Jaw lift

            [pic]   Oral airway

            [pic]   Nasal trumpet

        [pic]   AMBU bag

[pic]   Dental injury

[pic]   Equipment malfunctioning

[pic]   Equipment not available

[pic]   Failed sedation

    [pic]   Anesthesia called

    [pic]   Procedure terminated

[pic]   Incomplete bowel prep

[pic]   Incomplete procedure

[pic]   Nausea

[pic]   O2 at 10%< baseline for 2 minutes or more and/or 85%

[pic]   Required cardiopulmonary resuscitation (airway and circulation)

[pic]   Required cardiovascular medication administration

(list of meds comes up when drug given)

[pic]   Required reversal agent administration (comes up when drug given)

[pic]   Suspected aspiration

[pic]   Suspected perforation

[pic]   Unanticipated bleeding

[pic]   Uncooperative patient

[pic]   Vomiting

Vital signs

[pic]   Blood pressure

[pic]   Heart rate

[pic]   Heart rhythm

[pic]   Respiratory rate

[pic]   O2 saturation

[pic]   Capnography (CO2)

[pic]   Oxygen at ______liters

    [pic]   Time initiated

    [pic]   Time discontinued

    [pic]   How administered

            [pic]   Cannula

            [pic]   Mask

            [pic]   Tracheostomy

            [pic]   ET tube

In some situations, ICU nurse will be asked to stay to monitor patients in this condition; provision for linking to ICU documentation forms would be helpful.

Comments:

Specimens

(need option for multiple site selections with number of specimens and cm level 0-60)

Organ

[pic]   Esophagus

    [pic]   Mid _______cm

    [pic]   Proximal ________cm

    [pic]   Distal ________cm

    [pic]   Random

or

    [pic]   _____ specimens at _________cm

[pic]   Stomach

    [pic]   Esophagogastric junction

    [pic]   Cardia

    [pic]   Body

    [pic]   Fundus

    [pic]   Antrum

    [pic]   Pylorus

    [pic]   Random

    [pic]   H Pylori

[pic]   Duodenum

    [pic]   Duodenal bulb

[pic]   Jejunum

[pic]   Biliary tract

    [pic]   Ampulla

    [pic]   Common bile duct

[pic]   Common hepatic duct

    [pic]   Pancreatic duct

[pic]   Colon

    [pic]   Ileocecal valve

    [pic]   Ascending

    [pic]   Splenic flexure

    [pic]   Transverse

    [pic]   Hepatic flexure

    [pic]   Sigmoid

[pic]   Rectum

[pic]   Anus

Number of specimens from each site

(minimum 0, maximum 60)

[pic]

[pic]   Location (text)

Sent to laboratory for:

[pic]   Cytology

[pic]   Pathology

[pic]   Microbiology

[pic]  Specimens labeled and documented

(Labels to be generated by above information)

Media

Documentation video of [pic]

[pic]   #

[pic]   Disposition

[pic]   To patient

[pic]   To archives

[pic]   Documentation photo of [pic]

[pic]   #

[pic]   Disposition

    [pic]  To patient

    [pic]   To archives

    [pic]   To chart

Comments:

Therapeutic devices

[pic]   Argon plasma coagulator

    [pic]   Serial #/ Unit ID

    [pic]   Manufacturer

    [pic]   Site (pull from specimen list)

    [pic]   Gas Flow (check?)

    [pic]   Watts

    [pic]   Seconds

    [pic]   Pulses #

    [pic]   Watt seconds (multiplication of watts x seconds)

    [pic]   Balloons

            [pic]   Manufacturer

            [pic]   Serial #

            [pic]   Size(s)

                [pic]   French

                [pic]   Length

            [pic]   PSI (Pounds per square inch)

            [pic]   Time (minutes, seconds)

[pic]  Bicap hemostasis/heater probe

    [pic]   Manufacturer

    [pic]   Serial #

    [pic]   Probe size

    [pic]   Coagulation power (0-10)

    [pic]   Watts

[pic]   Biopsy forceps

    [pic]   Hot

            [pic]   upper

            [pic]   lower

    [pic]   Cold

            [pic]   upper

            [pic]   lower

    [pic]   Both

    [pic]   Manufacturer

    [pic]   Identification code

    [pic]   Number used

    [pic]   Type

(drop down menu per institution)

[pic]   Capsule

    [pic]   Signal verified

    [pic]   Lot #

    [pic]   Time ingested

Cautery

    [pic]   Manufacturer

    [pic]   Serial # / Unit ID

    [pic]   Settings

    [pic]   Watts

            [pic]   Monopolar

                [pic]   Cut (0-10 or range)

                [pic]   Coag (0-10 or range)

                [pic]   Blend (0-10 or range)

            [pic]   Bipolar

                [pic]   Cut (0-10 or range)

                [pic]   Coag (0-10 or range)

                [pic]   Blend (0-10 or range)

[pic]   Grounding Pad

    [pic]   Placement

            [pic]   Thigh

                [pic]   L

                [pic]   R

            [pic]   Other

    [pic]   Skin preparation

            [pic]   Yes

            [pic]   No

            [pic]   Not applicable

    [pic]   Skin condition at pad removal

            [pic]   Same as preprocedure

            [pic]   Erythematous

            [pic]   Abrasion

            [pic]   Other

[pic]   Cytology brush

    [pic]   Manufacturer

    [pic]   Identification code

    [pic]   Number used

    [pic]   Type (drop down per institution)

[pic]   Drain/stent

    [pic]   Type

            [pic]   Biliary

            [pic]   Colonic

            [pic]   Esophageal

    [pic]   Nasal Biliary

            [pic]   Pancreatic

[pic]   Rectal         

    [pic]   Manufacturer

    [pic]   Serial #

    [pic]   French (customize - pull from inventory)

_____cm

    [pic]   Length

[pic]   Dilatation

    [pic]   Balloons

            [pic]   Manufacturer

            [pic]   Serial #

            [pic]   Size(s)

                [pic]   French

                [pic]   Length

            [pic]   PSI (Pounds per square inch)

            [pic]   Time (minutes, seconds)

    [pic]   Bougie

            [pic]   Maloney

                [pic]   French

(multiple choice per institution, free text)

            [pic]   Hurst

                [pic]   French

(multiple choice per institution, free text)

    [pic]   Savary

            [pic]   Millimeters

[pic]   EMR Kit

    [pic]   Manufacturer

    [pic]   Serial # / Unit ID

    [pic]   Site

[pic]   Endocut

    [pic]   Type of probe

    [pic]   Filter change

    [pic]   Medications

            [pic]   Epinephrine

            [pic]   Normal saline

[pic]   ERCP

    [pic]   Basket

            [pic]   Serial #

            [pic]   French

[pic]   Cannulas

            [pic]   Serial #

            [pic]   French

    [pic]   Dilation catheter

   [pic] Serial #

   [pic]  French

    [pic]   Papillatome

            [pic]   Serial #

            [pic]   French

    [pic]   Stone retrieval

            [pic]   Balloon

            [pic]   Serial #

            [pic]   French

[pic]   Foreign body retrieval

    [pic]   Basket

    [pic]   Biopsy forceps

[pic]   Magnet

[pic]   Net

    [pic]   Rat tooth

    [pic]   Snare

    [pic]   Tripod

  [pic]   Other (free text)

[pic]   Fine needle aspiration needle

    [pic]   Manufacturer

    [pic]   Serial # / Unit ID

    [pic]   Size

[pic]   Guide wires

    [pic]   Manufacturer

    [pic]   Serial #

    [pic]   Size(s)

    [pic]   Number

    [pic]   Type

[pic]   Injection therapy

    [pic]   Site (from specimen list)

    [pic]   Needle serial #

    [pic]   Size

    [pic]   Medications/solutions

                        [pic]   Epinephrine

            [pic]   Ethanolamine

            [pic]   India ink

            [pic]   Normal saline

            [pic]   Sodium morruate

[pic]   Sodium tetradecyl

                [pic]   Dilution

                [pic]   Total amount

                [pic]   Increments

                [pic]   Number of injections

[pic]   Laser

    [pic]   Serial # / Unit ID

    [pic]   Manufacturer

    [pic]   Site

    [pic]   Gas Flow (check[pic]  )

    [pic]   Joules

    [pic]   Seconds

    [pic]   Pulses (#)

    [pic]   Joules Seconds (multiplication of watts times seconds)

[pic]   Motility/manometry catheter

    [pic]   Type

            [pic]   Water perfused

            [pic]   Solid state

    [pic]   Placement

            [pic]   Esophageal

                [pic]   Location

                            [pic]   R Nares

                            [pic]   L Nares

                            [pic]   Oral

                [pic]   ___________ cm

[pic]   Rectal

[pic]   ___________ cm

[pic]   Biliary

[pic]   Pancreatic

[pic]   Percutaneous endoscopic gastrostomy/jejunostomy

    [pic]   Manufacturer

    [pic]   Serial #

    [pic]   French (range)

[pic]   pH Probe

    [pic]   Manufacturer

    [pic]   Serial #

    [pic]   Unit ID

    [pic]   Placement

            [pic]   Location

                [pic]   R Nares

                [pic]   L Nares

                [pic]   Oral

            [pic]   ___________ cm

    [pic]   On medications

            [pic]   Yes

            [pic]   No

    [pic]   Time probe inserted

    [pic]   Date probe inserted

    [pic]   Time probe removed

    [pic]   Date probe removed

[pic]   Snares

    [pic]   Manufacturer

    [pic]   Serial #

    [pic]   Size(s)

    [pic]   Number

    [pic]   Type

[pic]   Spray catheter

    [pic]   Acetylcysteline

[pic]   Lugols solution

    [pic]   Methylene Blue

[pic]   Variceal ligation

    [pic]   Banding

            [pic]   number of bands

            [pic]   site

[pic]   Standard equipment in room (optional to list)

Comments:

Sedation monitoring

[pic]   Aldrete scoring

    [pic]   Activity

            [pic]   Able to move 4 extremities (2)

            [pic]   Able to move 2 extremities (1)

            [pic]   Able to move 0 extremities (0)

    [pic]   Respiration

            [pic]   Deeply breaths, coughs freely (2)

            [pic]   Dyspnea or limited breathing (1)

            [pic]   Apneic (0)

 [pic]   Circulation

      [pic]   Systolic BP +/- 20 mmHg pre-

procedure level (2)

[pic]   Systolic BP +/- 20 mmHg to 50

mmHg pre-procedure level (1)

[pic]   Systolic BP +/- 50 mmHg or

more of pre-procedure level (0)   

[pic]   Consciousness

            [pic]   Fully awake (2)

            [pic]   Arises on Calling (1)

            [pic]   Unresponsive (0)

    [pic]   Color

            [pic]   Pink (2)

            [pic]   Pale, dusky, blotchy,

jaundiced (1)

            [pic]   Cyanotic (0)

Patient position(s)

[pic]   Decubitus

[pic]   Fowlers

[pic]   Lateral

    [pic]   Left

    [pic]   Right

[pic]   Prone

[pic]   Semi-fowlers

[pic]   Supine

[pic]   Trendelenburg

Oral suction

[pic]   Yes

[pic]   No

Transportation to recovery room

[pic]   Ambulatory

[pic]   Wheel chair

[pic]   Via stretcher with side rails up

Intravenous fluids

(have system do the math to give total at end) (match pre-procedure list)

[pic]   Solution

    [pic]   D5/W

    [pic]   Normal saline

    [pic]   Lactated ringers

    [pic]   D5 1/2 NS

    [pic]   D5 1/4 NS

    [pic]   Packed red blood cells

    [pic]   Fresh frozen plasma

    [pic]   Platelets

            [pic]   Total amount infused

            [pic]   Site

    [pic]   Other

[pic]   Discontinued time

    [pic]   Catheter tip intact

            [pic]   Yes

            [pic]   No

    [pic]   Site with edema

            [pic]   Yes

            [pic]   No

    [pic]   Site with erythema

            [pic]   Yes

            [pic]   No

Medications

(computer enter name of administrator/time of administration)

[pic]   Antibiotics

(list most common used per institution)

[pic]   Bowel prep

 [pic]   Fleets enema

    [pic]   PEG solution

[pic]   Interventional medications

    [pic]   Cholecystokinen

    [pic]   Glucagon

 [pic]   Metaclopramide

    [pic]   Simethicone

[pic]   Sedation

[pic]   Diphanhydramine

    [pic]   Droperidol IV

    [pic]   Fentanyl IV

    [pic]   Meperidine IV

    [pic]   Midazolam IV

[pic]   Naxolone IV

    [pic]   Promethazine IV

[pic]   Propofol

[pic]   Romazicon IV

    [pic]   Other (free text)

[pic]   Topical anesthetics

    [pic]   Benzocaine Spray PO

[pic]   Lidocaine viscous

    [pic]   2% Lidocaine jelly

[pic]   Other medications

[pic]   Acetylcysteline

[pic]   Atropine

    [pic]   Epinepherine IV

    [pic]   Lugols solution

    [pic]   Lidocaine injectable

            [pic]   2%

            [pic]   4%

[pic]   Methylene Blue

[pic]   Sincalide IV

    [pic]   Free text

Radiation (Fluoroscopy)

[pic]   Patient shielded

    [pic]   Yes

    [pic]   No

    [pic]   Not applicable

[pic]   Fluoroscopy settings

[pic]   Contrast media

    [pic]   Amount

    [pic]   Type

            [pic]   Ionic

                [pic]   Full

                [pic]   Half

            [pic]   Non-ionic

                [pic]   Full

                [pic]   Half

            [pic]   Gastrograffin

[pic]   Total fluoroscopy time

[pic]   Time out of room

Comments:

POST-PROCEDURE

[pic]   Time admitted to recovery

Procedure(s) performed

(link to procedure(s) scheduled)

[pic]   Capsule Endoscopy

    [pic]  Scheduled

    [pic]  Repeated

[pic]   Colonoscopy

    [pic]  Scheduled

    [pic]  Repeated

    [pic]  Emergency

[pic]   Dilation

    [pic]  Scheduled

    [pic]  Repeated

    [pic]  Emergency

[pic]   EGD

    [pic]  Scheduled

    [pic]  Repeated

    [pic]  Emergency

[pic]   ERCP

    [pic]  Scheduled

    [pic]  Repeated

    [pic]  Emergency

[pic]   EUS

    [pic]  FNA

    [pic]  Scheduled

    [pic]  Repeated

[pic]   Flexible sigmoidoscopy

    [pic]  Scheduled

    [pic]  Repeated

    [pic]  Emergency

[pic]   Manometry and Motility

            [pic]   Biliary

            [pic]   Esophageal

            [pic]   Rectal

    [pic]  Scheduled

    [pic]  Repeated

[pic]   24 hour pH

    [pic]  Scheduled

    [pic]  Repeated

Vital signs

[pic]   Blood pressure

[pic]   Heart rate

[pic]   Heart rhythm

[pic]   Respiratory rate

[pic]   O2 saturation

[pic]   Capnography (CO2)

[pic]   Oxygen at ______liters

(link from pre-procedure)

    [pic]  Time initiated

    [pic]  Time discontinued

    [pic]  How administered

            [pic]   Cannula

            [pic]   Mask

            [pic]   Tracheostomy

            [pic]   ET tube

[pic]   Skin temperature

    [pic]  Warm

    [pic]  Cool

[pic]   Skin status

    [pic]  Dry

    [pic]  Moist

    [pic]  Intact

            [pic]   Yes

            [pic]   No

                [pic]  Body piercing

(free text to indicate location)

    [pic]  Other

Additional Tests

[pic]   EKG

[pic]   Glucometer

    [pic]  Blood glucose level

    [pic]  Time

    [pic]  Other

[pic]   Lab (drop menu with list)

[pic]   Radiology (drop menu with list)

Discharge instructions

(be sure JCAHO requirements are covered here)

Diet (can choose more than one)

[pic]   As tolerated

[pic]   Clear liquid

[pic]   Full liquid

[pic]   Gluten free

[pic]   High fiber

[pic]   Low fiber

[pic]   Low fat

[pic]   Return to normal

[pic]   Small frequent meals

[pic]   Soft

[pic]   Other (free text)

Limitations (These are examples – customize for individual institution)

[pic]   Do not drive any vehicle, drink alcohol, operate any dangerous equipment - such as power tools, lawn mowers, etc., or make any major decisions for at least 12 hours.

[pic]   Do not eat any solid food for one hour following the completion of the procedure.

[pic]   Do not take any aspirin, Advil, Nuprin, Alleve, BC powder, or ibuprofen for 7 days. Tylenol is acceptable.

[pic]   Fluids – encourage to drink

[pic]   Medication instructions

[pic]   Prescriptions provided

[pic]   Rest at home for the next 12 hours

[pic]   Questions invited and answered

    [pic]  Yes

    [pic]  No

    [pic]  Narrative (text)

Follow up appointment

[pic]   Office

[pic]   Procedure

Emergency follow up indicated for:

(examples – customize for individual facility)

[pic]   Any gastrointestinal bleeding > 1 tablespoon

[pic]   Any pain or red streaks near your IV site

[pic]   Nausea or vomiting lasting over 2 hours

[pic]   Referred pain to shoulder/neck area

[pic]   Severe or unusual abdominal discomfort or pain

[pic]   Temperature over 101 degrees F

[pic]   Call Dr. [pic]immediately at phone # [pic]

Post procedure teaching

[pic]   Date

[pic]   Time

[pic]   Method

    [pic]  Verbal

    [pic]  Video

    [pic]  Written

[pic]   Verbalizes understanding

[pic]   Individuals present for teaching

    [pic]  Patient

    [pic]  Spouse

    [pic]  Parent

    [pic]  Child

    [pic]  Sibling

    [pic]  Friend

    [pic]  Significant other

[pic]   Teaching content verbalized as understood by:

    [pic]   Patient

    [pic]   Spouse

    [pic]   Parent

    [pic]   Child

    [pic]   Sibling

    [pic]   Friend

    [pic]   Significant other

[pic]   Potential barriers to learning

    [pic]   Anxiety level

    [pic]   Cognitive ability

    [pic]   Hearing

    [pic]   Language

[pic]   Primary language

         [pic]   Translator utilized

    [pic]   Sight

[pic]   Teaching content

(drop-down menu with common discharge instruction worksheets to identify which one(s) were given to the patient/family/etc.)

[pic] People present for teaching

(write in names)

Post procedure devices in place

(those inserted during procedure)

[pic]   ET tube

[pic]   PEG/PEJ

[pic]   Rectal tube

[pic]   Stent (link to intraprocedure entry)

Post procedure devices retrieved

[pic]   Discharged with devices in place

[pic]   Retrieved prior to discharge

[pic]   ET tube

[pic]   PEG/PEJ

[pic]   Rectal tube

[pic]   Stent (link to intraprocedure entry)

Occurrences

[pic]   Admitted to hospital

[pic]   Allergic reaction

[pic]   Anesthesia

[pic]   Aspiration

[pic]   Bleeding

[pic]   Code

[pic]   Flumazemil administration

[pic]   Intubation

[pic]   IV infiltration

[pic]   Naloxone administration

[pic]   Nausea

[pic]   Perforation

[pic]   Readiness for discharge greater than 2 hours

[pic]   Vomiting

Comments:

Discharge

[pic]   Inpatient

    [pic]   Returned to room

    [pic]   Admitted to ICU

    [pic]   Transferred to another facility

    [pic]   Transported by

            [pic]   RN

            [pic]   LVN

            [pic]   Tech

            [pic]   Other

[pic]   Outpatient

    [pic]   Home

    [pic]   Admitted to room

    [pic]   Admitted to ICU

    [pic]   Returned to ER

    [pic]   Transferred to another facility

    [pic]  Accompanied by (specify name)

            [pic]   Family

            [pic]   Significant other

            [pic]   Ambulance staff

[pic]   Transportation

    [pic]   Public

    [pic]   Private

[pic]   Mode

    [pic]   Ambulatory

    [pic]   Wheel chair

    [pic]   Stretcher

[pic]   Report

    [pic]   Called

    [pic]   Given to

    [pic]   Given by

    [pic]   Not applicable

Assessment

[pic]   Abdominal assessment

    [pic]   Soft

    [pic]   Firm

    [pic]   Round

    [pic]   Flat

    [pic]   Distended

    [pic]   Tender

    [pic]   Nontender

    [pic]   Ascites

    [pic]   Passing flatus

[pic]   Gag reflex present

[pic]   Tolerating PO fluids

Intravenous access

[pic]   Site(s)

[pic]   Solution

    [pic]   D5/W

    [pic]   Normal saline

    [pic]   Lactated ringers

    [pic]   D5 1/2 NS

    [pic]   D5 1/4 NS

    [pic]   Packed red blood cells

    [pic]   Fresh frozen plasma (FFP)

    [pic]   Other

[pic]   Total amount infused

[pic]   Total amount remaining (system should

calculate from amt. hung and amt.

infused.)

[pic]   Discontinued time

[pic]   Type of dressing applied

[pic]   Catheter tip intact

    [pic]   Yes

    [pic]   No

[pic]   Site with edema

    [pic]   Yes

            [pic]   Site care instructions offered

    [pic]   No

[pic]   Site with erythema

    [pic]   Yes

            [pic]   Site care instructions offered

Aldrete scoring

[pic]   Activity

    [pic]   Able to move 4 extremities (2)

    [pic]   Able to move 2 extremities (1)

    [pic]   Able to move 0 extremities (0)

[pic]   Respiration

    [pic]   Deeply breaths, coughs freely (2)

    [pic]   Dyspnea or limited breathing (1)

    [pic]   Apneic (0)

[pic]   Circulation

    [pic]   Systolic BP +/- 20 mmHg pre-

procedure level (2)

    [pic]   Systolic BP +/- 20 mmHg to 50

mmHg pre-procedure level (1)

    [pic]   Systolic BP +/- 50 mmHg or more of

pre-procedure level (0)

[pic]   Consciousness

    [pic]   Fully awake (2)

    [pic]   Arises on Calling (1)

    [pic]   Unresponsive (0)

[pic]   Color

    [pic]   Pink (2)

    [pic]   Pale, dusky, blotchy, jaundiced (1)

    [pic]   Cyanotic (0)

Pain

[pic]   No

[pic]   Yes

    [pic]  Location

    [pic]   Duration

            [pic]   0-10

            [pic]   What 0-10 would be acceptable?

    [pic]   Frequency

    [pic]   Symptoms relieved by

    [pic]   Symptoms worsened by

    [pic]   Description

            [pic]   Free text

Belongings returned

[pic]   Dentures

[pic]   Glasses

[pic]   Hearing aids

[pic]   Other

Discharged by: (drop down menu with list of staff)

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