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ENDO Booking Form

Bluewater health Endo booking form

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ameliawood0988
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Download as PDF, TXT or read online on Scribd
21 views

ENDO Booking Form

Bluewater health Endo booking form

Uploaded by

ameliawood0988
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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BLUEWATER HEALTH– ENDOSCOPY BOOKING FORMS

Surgeon:
Patient
Patient Name:
Sex:
Patient Birth Date: Version
HCN:
DD/MM/YYYY Code:
Date of receipt of Patient Self Self-Delay
Referral Delay: Reason:

FAX THIS COMPLETED COVER PAGE WITH REQUIRED DOCUMENTS TO ENDO AT 519-346-4724
Dates affecting Readiness System DARC
to Consult (DARCs): Delays: Reason:

DARC DATES DD/MM/YYYY TO DD/MM/YYYY

Dates affecting Readiness System DART


to Treat (DARTs): Delays: Reason:

DART DATES: DD/MM/YYYY TO DD/MM/YYYY

Date of Procedure: Booked Days


HH:MM
DD/MM/YYYY Time: Waiting:
Primary Colonoscopy
Indication:
Select All that Apply
Secondary Indication Abnormal FIT cannot be a secondary indication for colonoscopy
for Colonoscopy SA FD CN OS
Select all that apply
Alerts: MH Latex MRSA Diabetes ESBL C Diff
Sleep
Apnea
Anesthesia Anesthesia
Admission Type
Type: Consult Required:

Required Documents:
 Consent Form
 Pre-Anesthesia Questionnaire
 Preoperative Order Set
 History and Physical
o If dictated, date:
 Lab Work (if completed at Life Labs and in your EMR)
 Consultation Notes (if in your EMR)
Notes:
Date of receipt of Referral: The date the referral for colonoscopy was received by the facility or Endoscopist.

Always prioritize abnormal FIT as the primary indication

Symptomatic (SA) – A patient with symptoms including changes in bowel habits, bleeding or discomfort or a patient with an abnormal lab test
(other than FIT) including barium enemas, CT scans, or other diagnostic imaging.
Abnormal FIT (FT) – A patient with an abnormal FIT result.
Surveillance (CN) – A patient who has had a prior colonoscopy in which an adenomatous polyp or colorectal cancer was found, and patients
who are undergoing surveillance for long-standing IBD.
First degree Relative (FD) – A patient with a first degree relative with colorectal cancer. First degree relatives include biological mother,
biological father, biological sister, biological brother, biological daughter or biological son.
Other Screening (OS) – A patient who has no other indication for the colonoscopy. For example, a patient having a colonoscopy for average-
risk primary screening or because of a family history of colorectal cancer other than first degree.
FAX THIS COMPLETED COVER PAGE WITH REQUIRED DOCUMENTS TO ENDO AT 519-346-4724
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