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Procedure Name
|
|
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Aborted RFA
|
|
|
Description
|
|
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Affected Vein Being Treated
• • •
|
|
|
Performing Physician
|
|
|
Registered Vascular Specialist/ Technologist
• • •
|
|
|
Performing Physician
|
|
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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 Last 4 Numbers ONLY
|
|
Access Points
|
|
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Pre-operative Diagnosis
• • •
|
Indication for Procedure
|
|
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Physical Assessment
|
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Procedure
|
|
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Procedure Description
|
|
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Modifier for Aborted Case
• • •
|
|
|
Post-Procedural Care
|
|
|
Consent
|
Authorization Sheet
|
|
HPI Note
|
|
