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DIAGNOSES
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PROCEDURE MATERIALS
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ICD-10 - SIJ - Required
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Needle size and type
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ICD-10 - SIJ
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Prep Solution
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MEDS - MISCELLANEOUS
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MEDICATIONS -Miscellaneous
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Lidocane 1% volume - mL
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Omnipaque 240 volume - mL
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Omnipaque 300 volume - mL
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Isovue - 300 volume - mL
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MEDICATIONS - BILATERAL
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Bupivacaine 0.25% volume - mL - Bilateral
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Dexamethasone (10 mg/ml) volume - mL - Bilateral
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Depo-Medrol (40 mg/ml) volume - mL - Bilateral
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MEDICATIONS - LEFT
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Bupivacaine 0.25% volume - mL - Left
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Dexamethasone (10 mg/ml) volume - mL - Left
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Depo-Medrol (40 mg/ml) volume - mL - Left
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MEDICATIONS - RIGHT
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Bupivacaine 0.25% volume - mL - Right
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Dexamethasone (10 mg/ml) volume - mL - Right
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Depo-Medrol (40 mg/ml) volume - mL - Right
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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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DIAGNOSTIC RESULTS
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DIAGNOSTIC RESULTS
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PROCEDURE
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BILATERAL SIJ
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LEFT SIJ
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RIGHT SIJ
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REPORT
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Procedure performed
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Injectate
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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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Bilateral 2
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Left 2
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Right 2
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Op report 2 - Normal Recovery
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Procedure Materials
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Prep Solution
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Needle size and type
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Medications (Miscellaneous)
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Omnipaque 240
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Omnipaque 300
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Isovue 300
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Lidocaine 1%
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Bilateral - bupivacaine
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Bilateral - Dexamethasone
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Depo-Medrol - Bilateral
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Left - bupivacaine
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Left - Dexamethasone
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Depo-Medrol - Left
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Right - bupivacaine
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Right - Dexamethasone
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Depo-Medrol - Right
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Recovery
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Diagnostic results
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