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DATE OF PROCEDURE:
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PROCEDURALIST:
• • •
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REFERRING PHYSICIAN:
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CHIEF COMPLAINT:
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PREPROCEDURE DIAGNOSES:
• • •
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POSTPROCEDURE DIAGNOSES:
• • •
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PROCEDURE NAME/SIDE
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PROCEDURE NAME/injectate
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PROCEDURE NAME/# in series
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PROC. NAME/Ultrasound
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PROC. NAME/Fluoroscopic:
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PROC. NOTE/Pt. position:
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PROCEDURE NOTE: (NEEDLE)
• • •
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PROC. NOTE/Local type
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PROC. NOTE/1mL Kenalog
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PROC. NOTE/1.5mL Kenalog
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PROC. NOTE/2mL Kenalog
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Procedure note/ ORTHOVISC 15mg/ml
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Procedure Note/ MONOVISC 22mg/ml
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PROCEDURE NOTE/Ultrasound
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PROC. NOTE/Fluoroscopic
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FINDINGS/Pre-proc (0-10)
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FINDINGS/Post-proc (0-10)
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FINDINGS/Post-proc VS:
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PLAN:
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