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EHR Report Title
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In Conjunction With
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In Conjunction With
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Initial LTC facility Consultation
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CC/HP heading
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Most recent LTC facility admission date
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Reason for admission
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Lower Extremity COMPLAINTS/suffers
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any OTHER reason for consultation: ________
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Other Lower Extremity Complaints
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referral text
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Additional Hx of Lower Extremity Dx
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Additionally, he/she reports_____.
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Suffering for more than # months
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Intermittent CLAUDICATION
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Rutherford Description
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Venous Symptoms interfere with daily activities
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Leg Pain severity scale (0-10 scale)
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Venous Symptoms are worse...
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Venous Symptoms are slightly better with...
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Has difficulty sitting >_____minutes
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Has difficulty standing >_____minutes
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ADDITIONAL RISK FACTORS
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Additional risks include _______.
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Has the patient been manages medically for comorbility relating to vascular disease?
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Prior Vascular Treatments & Conservative Management
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Prior Vascular Therapies?
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Prior Vein Surgery/Procedures
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Sclerotherapy/ablation- broadly described
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Stripping
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Right - sclerotherapy/ablation
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Left - sclerotherapy/ablation
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Iliac Vein Endovascular revascularization
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OTHER surgery/intervention: Status Post...
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Prior Arterial Surgery/Procedures
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Arterial Endovascular revascularization
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Name of Artery and intervention/surgery
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OTHER surgery/intervention: Status Post...
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Conservative management
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MVP non-clinical 'capacity' score
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MVP 'capacity' reference sheet
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