|
RFA
|
Venaseal
|
|
Varithena
|
Sclerotherapy ONLY
|
|
Spot Venaseal
|
|
|
RFA Vein Treated
• • •
|
Venaseal Vein Treated
• • •
|
|
Varithena Vein Treated
• • •
|
Sclerotherapy Vein Treated
• • •
|
|
Treatment Number/Step
|
Total # of treatments
|
|
DVT check negative
• • •
|
|
|
+DVT/SVT Venous US Right leg
• • •
|
+DVT/SVT Venous US Right leg
• • •
|
|
EHIT Classification
|
Comments/Free Text
|
|
Indication
|
Tumescent used
|
|
Pre-op Medication
|
Timeout Performed
|
|
Free Text
|
|
|
Procedure
|
|
|
Right Leg RFA
|
Left Leg RFA
|
|
Right Leg Venaseal
|
Left Leg Venaseal
|
|
Right Leg Varithena
|
Left Leg Varithena
|
|
Right Leg Sclerotherapy
|
Left Leg Sclerotherapy
|
|
Vein R Leg RFA 1st access
|
Size in mm
|
|
Insertion
|
Ref Vein R leg RFA
|
|
Placement
|
|
|
Cycles
|
Repeats
|
|
Vein Length
|
|
|
Time minutes
|
Seconds
|
|
RFA R 2nd Vein/Access?
|
|
|
Vein R Leg RFA 2nd
|
Size in mm
|
|
Insertion
|
Ref Vein R leg RFA
|
|
Placement
|
|
|
Cycles
|
Repeats
|
|
Vein Length
|
|
|
Time minutes
|
Seconds
|
|
RFA R 3rd Vein/Access?
|
|
|
Vein R Leg RFA 3rd
|
Size in mm
|
|
Insertion
|
Ref Vein R leg RFA
|
|
Placement
|
|
|
Cycles
|
Repeats
|
|
Vein Length
|
|
|
Time minutes
|
Seconds
|
|
RFA R 4th Vein/Access?
|
|
|
Vein R Leg RFA 4th
|
Size in mm
|
|
Insertion
|
Ref Vein R leg RFA
|
|
Placement
|
|
|
Cycles
|
Repeats
|
|
Vein Length
|
|
|
Time minutes
|
Seconds
|
|
Vein L Leg RFA 1st access
|
Size in mm
|
|
Insertion
|
Ref Vein L leg RFA
|
|
Placement
|
|
|
Cycles
|
Repeats
|
|
Vein Length
|
|
|
Time minutes
|
Seconds
|
|
RFA L 2nd Vein/Access?
|
|
|
Vein L Leg RFA 2nd
|
Size in mm
|
|
Insertion
|
Ref Vein L leg RFA
|
|
Placement
|
|
|
Cycles
|
Repeats
|
|
Vein Length
|
|
|
Time minutes
|
Seconds
|
|
RFA L 3rd Vein/Access?
|
|
|
Vein L Leg RFA 3rd
|
Size in mm
|
|
Insertion
|
Ref Vein L leg RFA
|
|
Placement
|
|
|
Cycles
|
Repeats
|
|
Vein Length
|
|
|
Time minutes
|
Seconds
|
|
RFA L 4th Vein/Access?
|
|
|
Vein L Leg RFA 4th
|
Size in mm
|
|
Insertion
|
Ref Vein L leg RFA
|
|
Placement
|
|
|
Cycles
|
Repeats
|
|
Vein Length
|
|
|
Time minutes
|
Seconds
|
|
Vein R Leg Venaseal 1st access
|
Size in mm
|
|
Insertion
|
Ref Vein R leg Venaseal
|
|
Placement
|
Vein Length
|
|
Venaseal R 2nd Vein/Access?
|
|
|
Vein R Leg Venaseal 2nd
|
Size in mm
|
|
Insertion
|
Ref Vein R leg Venaseal
|
|
Placement
|
Vein Length
|
|
Venaseal R 3rd Vein/Access?
|
|
|
Vein R Leg Venaseal 3rd
|
Size in mm
|
|
Insertion
|
Ref Vein R leg Venaseal
|
|
Placement
|
Vein Length
|
|
Venaseal R 4th Vein/Access?
|
|
|
Vein R Leg Venaseal 4th
|
Size in mm
|
|
Insertion
|
Ref Vein R leg Venaseal
|
|
Placement
|
Vein Length
|
|
Vein L Leg Venaseal 1st access
|
Size in mm
|
|
Insertion
|
Ref Vein L leg Venaseal
|
|
Placement
|
Vein Length
|
|
Venaseal L 2nd Vein/Access?
|
|
|
Vein L Leg Venaseal 2nd
|
Size in mm
|
|
Insertion
|
Ref Vein L leg Venaseal
|
|
Placement
|
Vein Length
|
|
Venaseal L 3rd Vein/Access?
|
|
|
Vein L Leg Venaseal 3rd
|
Size in mm
|
|
Insertion
|
Ref Vein L leg Venaseal
|
|
Placement
|
Vein Length
|
|
Venaseal L 4th Vein/Access?
|
|
|
Vein L Leg Venaseal 4th
|
Size in mm
|
|
Insertion
|
Ref Vein L leg Venaseal
|
|
Placement
|
Vein Length
|
|
Vein R Leg Varithena 1st access
|
Size in mm
|
|
Foam Amount Used
|
|
|
Varithena R 2nd Vein/Access?
|
|
|
Vein R Leg Varithena 2nd
|
Size in mm
|
|
Foam Amount Used
|
|
|
Vein L Leg Varithena 1st access
|
Size in mm
|
|
Foam Amount Used
|
|
|
Varithena L 2nd Vein/Access?
|
|
|
Vein L Leg Varithena 2nd
|
Size in mm
|
|
Foam Amount Used
|
|
|
Sclerotherapy Right Leg
|
|
|
Sclerosant Used
|
Foam Concentration
|
|
Sclero Right Leg Vein
|
Size in mm
|
|
Sclero Right Leg Vein
|
Size in mm
|
|
Sclero Right Leg Vein
|
Size in mm
|
|
Sclero Right Leg Vein
|
Size in mm
|
|
Sclero Right Leg Vein
|
Size in mm
|
|
Sclero Right Leg Vein
|
Size in mm
|
|
Sclero Right Leg Vein
|
Size in mm
|
|
Sclero Right Leg Vein
|
Size in mm
|
|
Sclero Right Leg Vein
|
Size in mm
|
|
Sclero Right Leg Vein
|
Size in mm
|
|
Sclerotherapy Left Leg
|
|
|
Sclerosant Used
|
Foam Concentration
|
|
Sclero Left Leg Vein
|
Size in mm
|
|
Sclero Left Leg Vein
|
Size in mm
|
|
Sclero Left Leg Vein
|
Size in mm
|
|
Sclero Left Leg Vein
|
Size in mm
|
|
Sclero Left Leg Vein
|
Size in mm
|
|
Sclero Left Leg Vein
|
Size in mm
|
|
Sclero Left Leg Vein
|
Size in mm
|
|
Sclero Left Leg Vein
|
Size in mm
|
|
Sclero Left Leg Vein
|
Size in mm
|
|
Sclero Left Leg Vein
|
Size in mm
|
|
Total Foam Used Right Leg
|
Total Foam Used Left
|
|
Spot Venaseal amount used (1st vein)
|
Perf/Vein Location spot Venaseal
|
|
Size in mm (1st spot perf)
|
Lot # Venaseal Adhesive (spot)
|
|
Spot Venaseal amount used (2nd vein)
|
Perf/Vein Location spot Venaseal
|
|
Size in mm (2nd spot perf)
|
Lot # Venaseal Adhesive (spot)
|
|
Spot Venaseal amount used (3rd vein)
|
Perf/Vein Location spot Venaseal
|
|
Size in mm (3rd spot perf)
|
Lot # Venaseal Adhesive (spot)
|
|
Lot # RFA
|
Serial # Varithena
|
|
Lot # Venaseal Kit
|
Lot # Venaseal Adhesive
|
|
Aborted Veins
• • •
|
|
|
End Procedure RFA Text
|
End Procedure Venaseal Text
|
|
End Procedure Varithena Text
|
End Procedure Sclero only Text
|
|
Performed by
|
Assisted by DFW
|
|
Assisted by Houston
|
Assisted by San Antonio
|
|
Next Visit Leg/Procedure
• • •
|
Next Visit Vein(s)
• • •
|
|
Comments/Free Text
|
|
