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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