Procedure Report - PDF document

Procedure Report ColonoscopyEndoSo� Surgery Center135 BroadwaySchenectady, New York 12305Pa�ent 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 complica�onSignature: _________________________________________________ Debbie Doe, MD November 11, 2011Dr. Frank Black1234 Main StreetSchenectady, NY 12144Dear Dr. Black:Today an endoscopic procedure was performed on your pa�ent John Smith.Following is a synopsis of the

endoscopy report and my ini�al recommenda�ons:Procedure Performed:Colonoscopy - Complete to terminal ileumIndica�ons:Blood in stool.Normal colon to the Terminal ileum.Internal Hemorrhoids.Internal Hemorrhoids.Recommenda�ons:Follow-up procedure in 10 yearsCon�nue Current Medica�ons.High �ber diet.Await biopsy results.Thank you for the opportunity to assist you in the care of this pa�ent. The �ndings werediscussed with Mr. Smith today along with the recommenda�ons 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 12144Pa�ent 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

i�edJar 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 yearsCon�nue current medica�onsHigh �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 Instruc�ons ColonoscopyEndoSo� Surgery Center135 BroadwaySchenectady, NY 12144Pa�ent 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 preven�on of complica�ons, please follow the instruc�ons 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:Prescrip�ons Given to Pa�ent:Appointment Informa�on:Call for an appointment with Dr. Frank Black in 2 weeks.Addi�onal Wri�en Instruc�ons Provided to Pa�ent: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 di�culty contac�ng your physician, callEndoSo�, LLC135 Broadway, Schenectady, NY, 12305Tel: (518) 831-8000Instruc�ons 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 instruc�ons and follow-up medical care.Pa�ent Signature: John Smith Date/Time: 11/11/2011, 07:56:49Pa�ent Representa�ve Signature: Jane Smith Doe Date/Time: 11/11/2011, 07:56:49 PHOTOREPORT by EndoSo�