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Chaperone?
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NAME OF CHAPERONE
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CHAPERONE
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DIAGNOSES
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PROCEDURE MATERIALS
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ICD-10 - BURSA - Required
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Needle size and type
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ICD-10 - BURSA
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Prep Solution
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MEDS - MISCELLANEOUS
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PATIENT POSITIONING
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Lidocane 1% volume - mL
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Position
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PRP INFORMATION
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VOLUME OF PRP INJECTED (mL)
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BURSAE INJECTED
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BILATERAL
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BILATERAL bursae
• • •
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LEFT bursa - bilateral
• • •
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RIGHT bursa - bilateral
• • •
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LEFT
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LEFT bursa
• • •
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RIGHT
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RIGHT bursa
• • •
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IMPORTANT HISTORY
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RECOVERY ROOM
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IMPORTANT HISTORY
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RECOVERY
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COMMENTS
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COMMENTS
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PROCEDURE
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BILATERAL Bursae
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LEFT Bursa
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NUMBER INJECTED - LEFT
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1 BURSA - Left
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2 or MORE BURSAE - Left
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RIGHT Bursa
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NUMBER INJECTED - RIGHT
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1 BURSA - Right
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2 or MORE BURSAE - Right
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REPORT
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Important History
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Diagnosis
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Diagnosis #1 - Required
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Diagnosis #2
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Bilateral 1
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Left 1
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Right 1
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Op report 1
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Op report 2 - Position
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Bilateral 2
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Left 2 - 1 bursa
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Left 2 - Multi bursa
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Right 2 - 1 bursa
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Right 2 - Multi bursa
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Op report 3 - Op details
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Bilateral 3
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Left 3 - 1 bursa
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Left 3 - Multi bursa
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Right 3 - 1 bursa
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Right 3 - Multi bursa
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Op report 4 - Normal Recovery
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Bursae Injected
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Bilateral Bursae
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Left Bursa - bilateral
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Right Bursa - bilateral
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Left Bursa
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Right Bursa
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Comments
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Procedure Materials
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Prep Solution
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Needle size and type
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Lidocaine 1%
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PRP Details
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Volume of PRP
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Recovery
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Chaperone
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