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Procedure Name
|
|
|
CPT Code
|
|
|
Description
|
|
|
Affected Vein Being Treated
• • •
|
|
|
Performing Physician
|
|
|
Performing Physician
|
|
|
Registered Vascular Specialist
• • •
|
|
|
Service Location
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|
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Location
|
|
|
|
|
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Brief History
|
|
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Operation
• • •
|
Cannister Lot Number
|
|
Access Points
|
|
|
Pre-operative Diagnosis
• • •
|
Indication for Procedure
|
|
Symptoms Experienced
• • •
|
Physical Assessment
|
|
Patient Education
|
|
|
Procedure
|
|
|
Procedure Description
|
|
|
Post-Procedural Care
|
|
|
|
|
|
Consent
|
|
|
HPI Note
|
|
