PHOTOREPORT by EndoSox00660074 This procedure was electronically signed ox00660066 on 04262013 085649 AM By Debbie Doe MD INSTRUMENTS QUALITY OF BOWEL PREP AdequateMEDICATIONS Ve ID: 940934
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Procedure Report ColonoscopyEndoSo Surgery Center135 BroadwaySchenectady, New York 12305Paent Name: Date of Birth: Record Number: Date / Time of Procedure:04/26/2013, 07:56:49Referring Physician:Frank Black, MDEndoscopist: Debbie Doe, MDPROCEDURE PERFORMED: Colonoscopy - complete to terminal ileum.INDICATIONS FOR EXAMINATION: PHOTOREPORT by EndoSo This procedure was electronically signed o on: 04/26/2013, 08:56:49 AM By Debbie Doe, MD INSTRUMENTS: QUALITY OF BOWEL PREP: AdequateMEDICATIONS: Versed 3mg IVP, Fentanyl 100 mg IV CPT Code: 45384 Colonoscopy, exible, proximal to splenic exure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery. 578.1 / R19.5 Blood in stool455.0 / K64.8 Internal hemorrhoids without complicaonSignature: _________________________________________________ Debbie Doe, MD November 11, 2011Dr. Frank Black1234 Main StreetSchenectady, NY 12144Dear Dr. Black:Today an endoscopic procedure was performed on your paent John Smith.Following is a synopsis of the
endoscopy report and my inial recommendaons:Procedure Performed:Colonoscopy - Complete to terminal ileumIndicaons:Blood in stool.Normal colon to the Terminal ileum.Internal Hemorrhoids.Internal Hemorrhoids.Recommendaons:Follow-up procedure in 10 yearsConnue Current Medicaons.High ber diet.Await biopsy results.Thank you for the opportunity to assist you in the care of this paent. The ndings werediscussed with Mr. Smith today along with the recommendaons and follow up arrangements.Please feel free to contact me if I can be of any further assistance.Sincerely, PHOTOREPORT by EndoSo Dr. Debbie DoeEndoSo Surgery Center135 BroadwaySchenectady, NY 12144 Pathology Request ColonoscopyEndoSo Surgery Center135 BroadwaySchenectady, NY 12144Paent Name: Date of Birth: Record Number: Date / Time of Procedure:Referring Physician:Frank Black, MDEndoscopist: PROCEDURE PERFORMED: Colonoscopy - complete to terminal ileum.INDICATIONS FOR EXAMINATIONBlood in stool.Tissue Subm
iedJar 1. biopsy from the ascending colon to exclude Crohn’s disease. Normal to the terminal ileumInternal hemorrhoidsENDOSCOPIC DIAGNOSIS:Normal colonInternal hemorrhoidsRECOMMENDATIONS:Follow-up procedure in 10 yearsConnue current medicaonsHigh ber dietAwait biopsy resultsSignature: _________________________________________________ Debbie Doe, MDCPT Code: 45384 Colonoscopy, exible, proximal to splenic exure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery. 578.1 Blood in stool PHOTOREPORT by EndoSo Discharge Instrucons ColonoscopyEndoSo Surgery Center135 BroadwaySchenectady, NY 12144Paent Name: Date of Birth: Record Number: Date / Time of Procedure:Referring Physician: Frank Black, MDEndoscopist: You have had the following procedure performed:Colonoscopy - Complete to terminal illeumTo aid in the prevenon of complicaons, please follow the instrucons given below:Tylenol. No Aspirin or NSAID such as Motrin,
Advil, Aleve, or any other Ibuprofen for 5 days.Do NOT drink alcoholic beverages for 24 hours.Do NOT drive or operate machinery for the remainder of today.Do NOT make major decisions, sign contracts, etc. for 24 hours.Discharged To:Prescripons Given to Paent:Appointment Informaon:Call for an appointment with Dr. Frank Black in 2 weeks.Addional Wrien Instrucons Provided to Paent:You should call your doctor, Dr. Frank Black (518)831-8000 , if you experience anyrectal bleeding, unusual pain, fever, dizziness, or any other problems.If you have diculty contacng your physician, callEndoSo, LLC135 Broadway, Schenectady, NY, 12305Tel: (518) 831-8000Instrucons on this form have been reviewed with John Doe and escort.Physician Signature: Debbie Doe, MD Date/Time: 11/11/2011, 07:56:49 AMI have received a copy and understand the instrucons and follow-up medical care.Paent Signature: John Smith Date/Time: 11/11/2011, 07:56:49Paent Representave Signature: Jane Smith Doe Date/Time: 11/11/2011, 07:56:49 PHOTOREPORT by EndoSo