|
Procedure
• • •
|
Indication (diagnosis)
|
|
Procedure Note/Comments
|
|
|
Consent Obtained
|
Consent Comments
|
|
Performing Physician
• • •
|
anesthesia dose if applicable
|
|
Previous Biopsy
|
Comments
|
|
Previous Therapy
|
|
|
Ultrasound
|
Staff
|
|
|
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
|
|
|
|
|
Pelvic Diagram
|
Pelvic Exam Comments
|
|
Follow Up
|
|
|
|
|
|
Labs
• • •
|
Lab Comments
|
|
Radiology
• • •
|
Radiology Comments
|
|
Sent to Lab
|
|
|
General Instructions
• • •
|
General Instruction Comments
|
|
Referrals
|
Referral Comments
|
|
Education
|
Education Comments
|
