|
Procedure
• • •
|
|
|
Indication (diagnosis)
|
|
|
LMP
|
Last Pap Smear
|
|
Consent Obtained
|
Consent Comments
|
|
Performing Physician
• • •
|
|
|
Anesthesia
|
anesthesia dose if applicable
|
|
Previous Biopsy
|
Comments
|
|
Previous Therapy
|
|
|
Ultrasound
|
Ultrasound Comments
|
|
Colposcopy
|
|
|
Colposcopy Findings
• • •
|
Comments
|
|
Biopsy Obtained from
• • •
|
Comments
|
|
EBL
• • •
|
Comments
|
|
Colopscopy Diagram
|
|
|
EMB
|
|
|
EMB, successful
|
|
|
Injection
|
|
|
Staff
|
|
|
Medication/Solution
• • •
|
Dose
|
|
Lot#
|
Expiration Date
|
|
Site
|
NDC
|
|
|
Procedure
|
|
Incision and Drainage or Excision
|
|
|
I&D successful
|
Comments
|
|
Excision successful
|
Comments
|
|
IUD
|
|
|
IUD insertion successful
|
Comments
|
|
IUD removal successful
|
Comments
|
|
Lot#
|
Expiration Date
|
|
Serial Number
|
|
|
Nexplanon
|
|
|
Site
|
|
|
Nexplanon Insertion Successful
|
Comments
|
|
Lot#
|
Serial Number
|
|
|
Expiration Date
|
|
Nexplanon Removal Successful
|
Comments
|
|
TCA
|
|
|
TCA applied to
|
Comments
|
|
Tolerated well
|
Comments
|
|
General WNL
|
General Abnormal
• • •
|
|
|
Comments
|
|
Neck WNL
|
Neck Abnormal
• • •
|
|
|
Neck Comments
|
|
Skin WNL
|
Skin Lesion
|
|
|
Comments
|
|
Pelvic Exam Normal
|
Pelvic Exam Comments
|
|
Pelvic Diagram
|
|
|
External Genitalia
|
External Genitalia
• • •
|
|
|
External Genitalia Comments
|
|
Urethral Meatus
|
Urethral Meatus
• • •
|
|
|
Urethral Meatus Comments
|
|
Bladder Normal
|
Bladder
• • •
|
|
|
Bladder Comments
|
|
Vagina Normal
|
Vagina
• • •
|
|
|
Vagina Comments
|
|
Cervix Normal
|
Cervix
• • •
|
|
|
Cervix Comments
|
|
Uterus Normal
|
Uterus
• • •
|
|
|
Uterus Comments
|
|
Adnexa Normal
|
Adnexa
• • •
|
|
|
Adnexa Comments
|
|
Anus/Perineum
|
Anus/Perieum
• • •
|
|
|
Anus/Perineum Comments
|
|
Rectal
|
Rectal
• • •
|
|
|
Rectal Comments
|
|
MSK WNL
|
MSK Abnormal
• • •
|
|
|
Comments
|
|
Extremities WNL
|
Extrem Abnormal
• • •
|
|
|
Comments
|
|
Neuro WNL
|
Neuro Abnormal
• • •
|
|
|
Comments
|
|
Assessment
|
|
|
Labs
• • •
|
Lab Comments
|
|
Sent to Lab
|
|
|
General Instructions
• • •
|
General Instruction Comments
|
|
Referrals
|
Referral Comments
|
|
Education
|
Education Comments
|
