Description:

Form from HIS OpenVistA

Keywords:
Versions (6) ▾
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  2. 8/7/14
  3. 8/7/14
  4. 8/8/14
  5. 8/9/14
  6. 8/28/15
Uploaded on:

August 28, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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ENDOSCOPY PRE PROCEDURE ID RECORD

HIS

  1. StudyEvent: HIS
    1. HIS
General Info
CONDITION UPON ARRIVAL (stable, unstable)
LEVEL OF CONSCIOUSNESS
PATIENT ID BAND ON WITH CORRECT NAME, DOB AND PHYSICIAN
LANGUAGE BARRIER
TRANSLATOR (yes, N/A)
PHYSICAL DISABILITIES
Dental
Hearing
Visual
%
kg
cm
PRE-OP DIAGNOSIS
Abnormal GI Xray
Abdominal Pain
Abnormal weight loss (finding)
Achalasia
Anaemia
Ascites
Irregular bowel habits
Liver Cirrhosis
Screening for Colorectal Cancer
Common Bile Duct Leak
Common Bile Duct Stone
Constipation
Diarrhea
Indigestion
Deglutition Disorders
Elevated Liver Function Tests
Oesophageal Varices
Family History of Colon Cancer
Family History of Polyps
Family History of Polyposis
Foreign Body in Colon
Foreign Body in Esophagus
Foreign Body in Stomach
Peptic Ulcer
Gastroesophageal reflux disease (GERD)
Gastrointestinal Hemorrhage
Haematemesis
History of Barrett's
History of Cholangiocarcinoma
History of Colon Cancer
History of Crohn's Disease
History of Diverticulosis
History of Esophageal Cancer
History of Esophageal/ Gastric Varicies
History of Gastric Cancer
History of Pancreatic Cancer
History of Peptic Ulcer Disease
History of Polyps
History of Ulcerative Colitis
Blood in Stool
Iron Deficiency Anaemia
Icterus
Melaena
Nausea
Emesis
Occult/Guaiac Positive Stool
Pancreatitis
Portal Hypertension
gastric reflux
Abnormal weight loss
PRE-PROCEDURE ALDRETE SCORE
ACTIVITY
RESPIRATORY
BLOOD PRESSURE
LEVEL OF CONSCIOUSNESS
EVALUATION OF SKIN CONDITION AND COLOR