|
Diagnostic test date
|
|
|
Ordering provider
|
|
|
Indication-post op study
• • •
|
|
|
Examination-laterality
|
|
|
GSV Exam-distal portion tx'd
|
|
|
SSV Exam-prox treatment
|
|
|
SSV Exam-distal pt treated
|
|
|
Tributaries at 2 & 6 wks
• • •
|
|
|
First Trib locale
|
|
|
First Trib meas.
|
|
|
First Trib reflux
|
|
|
Second Trib locale
|
|
|
Second Trib meas
|
|
|
Second Trib reflux
|
|
|
Third Trib locale
|
|
|
Third Trib meas
|
|
|
Third Trib reflux
|
|
|
Fourth Trib meas
|
|
|
Fourth Trib locale
|
|
|
Fourth Trib reflux
|
|
|
Fifth Trib locale
|
|
|
Fifth Trib meas
|
|
|
Fifth Trib reflux
|
|
|
Tributary comments
|
|
|
Perforators
|
|
|
# Perfs
|
|
|
Perf locale
• • •
|
|
|
Perforator comments
|
|
|
Images
|
|
|
Image Comments
|
|
|
Impression RFLA-select vein
|
|
|
Impression Phleb-select vein
• • •
|
|
|
Impression-time frame
|
|
|
Impression-select vein @ 6 weeks
• • •
|
|
|
Impression-tribs/perfs
• • •
|
|
|
Impression Comments
|
|
|
Ultrasound Technologist
|
|
