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LESI
|
with TPI (LESI)
|
|
|
with SI Joint
|
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PREOPERATIVE DIAGNOSIS
|
TPI Field
|
|
PreOp
|
|
|
POSTOPERATIVE DIAGNOSIS
|
TPI Field
|
|
PostOp
|
New Short Text Field
|
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PROCEDURE
|
TPI Field
|
|
Procedure
|
New Short Text Field
|
|
MAC [Yes] / Local [No] (SPRING)
|
|
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TIVA [Yes] / Local [No] (SPRING)
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MAC [Yes] / Local [No]
|
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TIVA [Yes] / Local [No] (CLEAR LAKE)
|
MAC [Yes] / Local [No] (CLEAR LAKE)
|
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INDICATION
|
TPI Field
|
|
Indication
|
New Short Text Field
|
|
OPERATIVE PROCEDURE
|
|
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Prep
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Comments
|
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Level
|
|
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Contrast Yes / No
|
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Steroid
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Procedure Comments
|
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Caudal ESI
|
with TPI (Caudal)
|
|
PREOPERATIVE DIAGNOSIS
|
TPI Field
|
|
POSTOPERATIVE DIAGNOSIS
|
TPI Field
|
|
PROCEDURE
|
TPI Field
|
|
TIVA [Yes] / Local [No]
|
MAC [Yes] / Local [No]
|
|
TIVA [Yes] / Local [No] (CLEAR LAKE)
|
MAC [Yes] / Local [No] (CLEAR LAKE)
|
|
INDICATION
|
TPI Field
|
|
OPERATIVE PROCEDURE
|
|
|
Prep
|
|
|
Contrast Yes / No
|
Procedure Comments
|
|
CESI
|
with TPI (CESI)
|
|
PREOPERATIVE DIAGNOSIS
|
TPI Field
|
|
POSTOPERATIVE DIAGNOSIS
|
TPI Field
|
|
PROCEDURE
|
TPI Field
|
|
MAC [Yes] / Local [No] (SPRING)
|
MAC [Yes] / Local [No]
|
|
TIVA [Yes] / Local [No] (SPRING)
|
MAC [Yes] / Local [No] (CLEAR LAKE)
|
|
INDICATION
|
TPI Field
|
|
OPERATIVE PROCEDURE
|
|
|
Prep
|
|
|
Level
|
|
|
Contrast Yes / No
|
|
|
Steroid Dose
|
Procedure Comments
|
|
Thoracic ESI
|
with TPI (TESI)
|
|
PREOPERATIVE DIAGNOSIS
|
TPI Field
|
|
POSTOPERATIVE DIAGNOSIS
|
TPI Field
|
|
PROCEDURE
|
TPI Field
|
|
TIVA [Yes] / Local [No]
|
IV Sedation [Yes] / Local [No]
|
|
INDICATION
|
TPI Field
|
|
OPERATIVE PROCEDURE
|
|
|
Prep
|
|
|
Level
|
|
|
Contrast Yes / No
|
Procedure Comments
|
|
Cervical Facet Medial Branch Block
|
|
|
POSTOPERATIVE DIAGNOSIS
|
|
|
PROCEDURE
|
|
|
TIVA [Yes] / Local [No]
|
IV Sedation [Yes] / Local [No]
|
|
INDICATION
|
|
|
OPERATIVE PROCEDURE
|
|
|
Prep
|
|
|
Facet Joint Location
• • •
|
Procedure Comments
|
|
Thoracic Facet Joint Injection
|
with TPI (Thoracic Facet)
|
|
PREOPERATIVE DIAGNOSIS
|
TPI Field
|
|
POSTOPERATIVE DIAGNOSIS
|
TPI Field
|
|
PROCEDURE
|
TPI Field
|
|
TIVA [Yes] / Local [No]
|
IV Sedation [Yes] / Local [No]
|
|
INDICATION
|
TPI Field
|
|
OPERATIVE PROCEDURE
|
|
|
Prep
|
|
|
Facet Joint Location
• • •
|
Procedure Comments
|
|
TFESI
|
with TPI (TFESI)
|
|
PREOPERATIVE DIAGNOSIS
|
TPI Field
|
|
POSTOPERATIVE DIAGNOSIS
|
|
|
PROCEDURE
|
TPI Field
|
|
|
with Other
|
|
TIVA [Yes] / Local [No]
|
IV Sedation [Yes] / Local [No]
|
|
MAC [Yes] / Local [No]
|
|
|
INDICATION
|
TPI Field
|
|
OPERATIVE PROCEDURE
|
|
|
Prep
|
|
|
Spinal Needle Size
|
|
|
Location / Level
• • •
|
|
|
Contrast Yes / No
|
|
|
Steroid / Level
|
Procedure Comments
|
|
Sacroiliac Joint Injection
|
with TPI (SI Joint)
|
|
PREOPERATIVE DIAGNOSIS
|
TPI Field
|
|
POSTOPERATIVE DIAGNOSIS
|
TPI Field
|
|
PROCEDURE
|
TPI Field
|
|
MAC [Yes] / Local [No] (SPRING)
|
MAC [Yes] / Local [No] (CLEAR LAKE)
|
|
TIVA [Yes] / Local [No] (SPRING)
|
IV Sedation [Yes] / Local [No]
|
|
TIVA [Yes] / Local [No] (CLEAR LAKE)
|
|
|
INDICATION
|
TPI Field
|
|
OPERATIVE PROCEDURE
|
|
|
Prep
|
|
|
SI Joint Location
|
|
|
Steroid Dose
|
Procedure Comments
|
|
TPI ONLY
|
|
|
TPI ONLY
|
|
|
PREOPERATIVE DIAGNOSIS
|
PREOPERATIVE DX
|
|
POSTOPERATIVE DIAGNOSIS
|
POSTOPERATIVE DX
|
|
PROCEDURE
|
|
|
TIVA [Yes] / Local [No] (SPRING)
|
IV Sedation [Yes] / Local [No]
|
|
TIVA [Yes] / Local [No] (CLEAR LAKE)
|
|
|
INDICATION
|
|
|
OPERATIVE PROCEDURE
|
Procedure Intro
|
|
TRIGGER POINT INJECTION (TPI)
|
|
|
Cervical (Right / Left)
|
Cervical (B/L)
|
|
Cervical / Trapezius (Right / Left)
|
Cervical / Trapezius (B/L)
|
|
Trapezius (Right / Left)
|
Trapezius (B/L)
|
|
Thoracic (Right / Left)
|
Thoracic (B/L)
|
|
Lumbar (Right / Left)
|
Lumbar (B/L)
|
|
TPI Comments
|
|
|
Tolerated well? Yes / No
|
Tolerated Procedure Free Write
|
|
Recovery / Discharge
|
Recovery / Discharge Free Write
|
|
Fluoroscopy Image #1
|
|
|
Fluoroscopy Image #2
|
|
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Fluoroscopy Image #3
|
|
|
Fluoroscopy Image #4
|
|
