|
Procedure Date:
|
Procedure:
|
|
Primary Care Physician:
|
Chief Complaint:
|
|
Vital Signs:
|
Ht/Wt
/
|
|
|
|
|
Pulses Right LE
• • •
|
Pulses Left LE
• • •
|
|
Pulses Right UE
• • •
|
Pulses Left UE
• • •
|
|
Photo
|
|
|
Ports/Catheter/Access
|
Access Type
|
|
Location
• • •
|
Site
• • •
|
|
Function
• • •
|
Assessment
• • •
|
|
ADDITIONAL NOTES
|
|
|
PHYSICAL EXAMINATION
|
HEENT
|
|
CHEST
|
CARDIOVASCULAR
|
|
ABDOMEN
|
EXTREMITIES
|
|
NEUROLOGICAL
|
Assessment/Codes
• • •
|
|
CARE PLAN
|
Arterial Doppler
• • •
|
|
Venous Doppler with Reflux
• • •
|
Carotid Imaging
• • •
|
|
Wound Culture/Location
|
Labs
|
|
Compression Stockings
|
Referrals
|
|
Medication/Refills
|
Follow Up
• • •
|
