|
Standard follow up
|
|
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Prescription medications
|
|
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Inhaler/spacer teaching
|
|
|
Ortho eqipment
• • •
|
No physical activity
|
|
Labs to be done by DLO:
• • •
|
Lab Comments
|
|
Referral:
• • •
|
Referral Comments
|
|
Procedure performed?
|
|
|
Venipuncture
|
I&D of abscess
|
|
Venipuncture performed by
|
Number of abscesses
|
|
Blood send to DLO?
|
Size and location (include laterality):
|
|
Cerumen removal
|
probing/loculations/irrigation/packing
• • •
|
|
Indication
• • •
|
Amount drained
|
|
New Single Select
|
Description of fluid
|
|
method of removal
|
Laceration repair
|
|
Splint application
|
Number of lacerations
|
|
Who applied splint?
|
Location (include laterality)
|
|
Location (include laterality)
|
Length of laceration
|
|
Type of prefabricated splint
|
Depth of laceration
|
|
Custom splint
|
Material(s) used
• • •
|
|
Type of custom splint
|
Number of sutures
|
|
Materials used
• • •
|
Number of staples
|
|
NV check
|
Layered closure
|
|
|
Extensive cleaning/foreign bodies?
|
