ࡱ> VXGHIJKLMNOPQRSTU'` ,bjbj$$ JNFF`M`M`M8MRph|SRBBB$h@fB*BwhB|pS @̯O`M4K@0pPb #^pDG`M`M PRE-PROCEDURE Date INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET Time of arrival INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET  AM/PMHistory obtained from:  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Patient  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Spouse  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Parent  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Child  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Sibling  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Friend  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Significant other  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Other Arrival mode  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Ambulatory  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Wheelchair  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Stretcher Transportation  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Private  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Public Arrived with:  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Alone  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Spouse  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Parent  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Child  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Sibling  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Friend  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Significant other Discharge arrangements  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Driver  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  In Lobby  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Need to call  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET  Signed generic post-op instructions  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Yes  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  No Date:  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET  Time:  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET  Reason for Procedure (use ICD9 codes if automated)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Abdominal pain  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Colorectal Cancer Screening  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Constipation  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Bleeding  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Dysphasia  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  GERD/heartburn  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  IBS  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Pain  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Other Scheduled procedure (pick multiple choices) (link this to post procedure to link with actual procedure performed)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  EGD  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Scheduled  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Repeated  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Unscheduled  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Endoscopic Ultrasound (EUS)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Fine Needle Aspiration (FNA)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Scheduled  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Repeated  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Flexible Sigmoidoscopy  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Scheduled  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Repeated  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Unscheduled  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Colonoscopy  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Scheduled  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Repeated  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Unscheduled  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  ERCP  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Scheduled  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Repeated  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Unscheduled  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Dilatation  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Scheduled  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Repeated  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Emergency  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Manometry & Motility  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Biliary  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Esophageal  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Rectal  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Scheduled  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Repeated  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET 24-hour pH  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Scheduled  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Repeated  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Capsule Endoscopy  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Scheduled  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Repeated Pre-op contact Date:  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET  Time:  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET  Person contacted INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET  Relationship  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET  Person who initiated contact  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET No Reason INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET  Procedure and patient verified  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Yes  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  No Reason: INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Patient  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Physician  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Family/significant other Patient issued:  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  ID band  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Allergy ID band  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Mastectomy band  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Not indicated  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Shunt band  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Not indicated Comments: Pre-op teaching Date:  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET  Time:  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET  Method  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Verbal  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Written  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Video  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Reason for procedure  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Verbalizes understanding Individuals present for teaching  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Patient  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Spouse  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Parent  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Child  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Sibling  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Friend  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Significant other Verbalized understanding of teaching content:  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Patient  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Spouse  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Parent  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Child  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Sibling  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Friend  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Significant other Potential barriers to learning  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Anxiety level  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Cognitive ability  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Hearing  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Language  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Sight Primary language  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET English  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Spanish Other  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Translator utilized People present for teaching (write in names)  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET  Comments: Review of medical history Previous sedation analgesia problems  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Fainted  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Hyperexcitability  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Hypotension  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Persistent nausea  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Persistent vomiting  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Prolonged sedation  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Tachycardia  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Unstable blood pressure  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  None Patient allergies  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Latex  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Meds  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Food  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Dye (radiology)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Other  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET  Previous medical procedures  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Mastectomy  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Right  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Left  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Shunt  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Right  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Left  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Heart  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Automatic internal cardiac defibrillator  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Hypertension  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Pacemaker  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Valve replacement  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Other INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Lung  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Asthma  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Chronic obstructive pulmonary disease  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Ostomy  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Liver/GI  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Yes (Comments: free text field)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Kidney/ GU  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Yes (Comments: free text field)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Airway (Mallampati classification per MD)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET 1-4  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Mouth opens adequately  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Airway patent  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Neuro/seizures  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Sleep apnea Orthopedic (flag intraprocedure grounding pad/pad placement)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Appliance  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Neck  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Back  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Upper extremity  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Left  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Right  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Lower extremity  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Left  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Right Significant family history  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Colorectal cancer  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Gardner syndrome  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Peutz-Jaegers Disease Medications  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Anticoagulants  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Aspirin  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Coumadin  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Plavix  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Heparin  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Date last taken  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Time last taken  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Herbals  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Date last taken  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Time last taken  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  MAO inhibitors  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Date last taken  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Time last taken  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Nonsteroidal anti-inflammatories  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Date last taken  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Time last taken Exposure to:  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  HIV  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Hepatitis A  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Hepatitis B  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Hepatitis C  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Sexually Transmitted Disease  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  TB  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Other (free text) Endocrine  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Insulin dependent/non-insulin dependent  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Last blood glucose  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Date  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Time Substance use  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Alcohol  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Amount (free text)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET None  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Caffeine  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Amount (free text)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET None  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Drugs  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Yes  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  History of (free text)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET None  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Tobacco  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Amount (free text)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Years  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET None History of:  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Glaucoma  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Previous endoscopic procedures (list)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Previous surgeries (list) Comments:  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET  Condition upon arrival  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  American Society of Anesthetists (ASA) Scoring (per physician)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET 1  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET 2  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET 3  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET 4  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET 5 Aldrete scoring per facility choice  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Activity  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Able to move 4 extremities (2)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Able to move 2 extremities (1)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Able to move 0 extremities (0)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Respiration  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Deeply breaths, coughs freely (2)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Dyspnea or limited breathing (1)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Apneic (0)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Circulation  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Systolic BP +/- 20 mmHg pre- procedure level (2)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Systolic BP +/- 20 mmHg to 50 mmHg pre-procedure level (1)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Systolic BP +/- 50 mmHg or more of pre-procedure level (0)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Consciousness  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Fully awake (2)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Arises on calling (1)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Unresponsive (0)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Color  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Pink (2)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Pale, dusky, blotchy, jaundiced (1)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Cyanotic (0)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Arrived in unit with oxygen at ______liters  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  How administered  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Cannula  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Mask  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Tracheostomy  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  ET tube Pain  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  No  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Yes  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Location  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Duration  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  0-10  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  What 0-10 would be acceptable for patient?  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Frequency  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Symptoms relieved by  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Symptoms worsened by  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Description  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Free text Vital sign base line readings  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Blood pressure  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Pulse  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Respiratory rate  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  O2 SAT  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Capnography (CO2)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Temperature Sedation plan  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Moderate  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Deep  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  General  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Local  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Topical General Assessment Skin temperature  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Warm  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Cool Skin status  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Dry  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Moist  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Intact  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Yes  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET No  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Body piercing (free text to note location)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Other Follows command  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Yes  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  No Psychological state  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Agitated  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Anxious  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Cooperative  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Oriented  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Restless  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Tranquil Weight  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Stated  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Actual Height  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Stated  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Actual Pregnant  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  No  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Yes  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Physician notified  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Date of last menstrual period Respiratory Assessment  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Clear  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Congested Abdominal assessment  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Distended  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Firm  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Flat  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Nontender  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Round  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Soft  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Tender Intravenous (IV) access  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Extremity restriction  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Left  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Right  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  New insertion  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Time  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Name of person inserting/credentials  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Type of IV (need option for more than 1 IV)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Size  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Number of attempts  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Patency  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Peripheral  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Angiocath  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Butterfly  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Other  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Central  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Triple lumen  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Port  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Site  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  L Hand  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  R Hand  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  L posterior forearm  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  R posterior forearm  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  L anterior forearm  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  R anterior of forearm  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  L anticubital space  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  R anticubital space  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Other  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Solution  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  D5/W  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Normal saline  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Lactated ringers  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  D5 1/2 NS  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  D5 1/4 NS  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Packed red blood cells  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Platelets  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Fresh frozen plasma (FFP)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Amount remaining  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Rate ordered  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Other  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Arrived with IV access in place  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Type of IV (need option for more than 1 IV)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Size  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Number of attempts  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Patency  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Peripheral  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Angiocath  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Butterfly  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Other  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Central  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Triple lumen  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Port  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Site  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  L Hand  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  R Hand  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  L posterior forearm  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  R posterior forearm  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  L anterior forearm  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  R anterior of forearm  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  L anticubital space  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  R antecubital space  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Other  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Solution  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  D5/W  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Normal saline  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Lactated ringers  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  D5 1/2 NS  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  D5 1/4 NS  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Packed red blood cells  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Platelets  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Fresh frozen plasma (FFP)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Amount remaining  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Rate ordered  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Other Oral Assessment  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Dentures  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Yes  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Removed  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Upper  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Lower  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Loose teeth  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Yes  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Location  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Tongue pierced Risk/screen  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Abuse  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Physical  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Emotional  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Mental  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Verbal  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Sexual  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Fall risk  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Nutrition  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Psychosocial Comments: Preparation for procedure  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  NPO  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Last solid food  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Date  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Time  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Last liquids ingested  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Date  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Time  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Bowel prep  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Type  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET PEG solution  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Biscodyl tablets  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Biscodyl suppositories  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Fleets enema  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Fleets oral  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Citrate of Magnesia  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Tap water enemas  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Soap suds enemas  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Visical  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Other  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Taken as instructed  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Yes  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET No  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Reason  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Description of last stool  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Consistency  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Liquid  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Semi-solid  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Solid  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Color  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Clear  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Yellow  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Brown  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Other Review of lab results  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  None ordered  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Within normal limits  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Physician notified of abnormality  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Not available Advance directives  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Living will  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Yes  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET No  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Additional information provided for patient  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Patient does not wish more information  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Durable power of attorney for medical affairs Belongings removed  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Dentures  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Glasses  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Hearing aids  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Other Disposition  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  With patient  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  With significant other  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Other  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Who completed assessment (track staff with number system- unique identifier per facility policy) Comments: INTRA-PROCEDURE Procedure and Patient re-verified  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Yes  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Patient  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Physician  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Family/significant other Verify allergies with patient  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  yes Verify sedation planned  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  yes Verify consent forms signed  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Procedure  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Sedation  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Observation (people in the room)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Permission to discuss findings with  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Procedure Room number  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Time entered room Personnel  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Nurse (drop down menu, free text)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  GI Tech (drop down menu, free text)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Radiology Tech (drop down menu, free text)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Attending physician (drop down menu, free text)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Fellow (drop down menu, free text)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Pathologist (drop down menu, free text)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Resident (free text)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Student (free text)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Observer (free text) Procedural information Scopes  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Scope utilized (drop down box with all available scopes)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Not applicable  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Scope ID number  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Time scope inserted in patient  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Time endoscopist reached cecum (only for colonoscopy)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Time scope removed from patient Events/Occurrences  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  None  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Abdominal pressure applied (link to colonoscopy/flex sigmoidoscopy procedures)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Allergic reaction  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Anatomical variances  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Compromised airway  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Required airway support  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  ET tube  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Jaw lift  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Oral airway  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Nasal trumpet  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  AMBU bag  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Dental injury  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Equipment malfunctioning  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Equipment not available  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Failed sedation  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Anesthesia called  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Procedure terminated  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Incomplete bowel prep  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Incomplete procedure  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Nausea  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  O2 at 10%< baseline for 2 minutes or more and/or 85%  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Required cardiopulmonary resuscitation (airway and circulation)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Required cardiovascular medication administration (list of meds comes up when drug given)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Required reversal agent administration (comes up when drug given)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Suspected aspiration  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Suspected perforation  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Unanticipated bleeding  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Uncooperative patient  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Vomiting Vital signs  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Blood pressure  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Heart rate  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Heart rhythm  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Respiratory rate  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  O2 saturation  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Capnography (CO2)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Oxygen at ______liters  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Time initiated  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Time discontinued  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  How administered  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Cannula  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Mask  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Tracheostomy  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  ET tube In some situations, ICU nurse will be asked to stay to monitor patients in this condition; provision for linking to ICU documentation forms would be helpful. Comments: Specimens (need option for multiple site selections with number of specimens and cm level 0-60) Organ  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Esophagus  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Mid _______cm  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Proximal ________cm  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Distal ________cm  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Random or  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  _____ specimens at _________cm  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Stomach  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Esophagogastric junction  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Cardia  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Body  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Fundus  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Antrum  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Pylorus  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Random  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  H Pylori  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Duodenum  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Duodenal bulb  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Jejunum  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Biliary tract  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Ampulla  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Common bile duct  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Common hepatic duct  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Pancreatic duct  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Colon  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Ileocecal valve  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Ascending  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Splenic flexure  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Transverse  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Hepatic flexure  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Sigmoid  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Rectum  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Anus Number of specimens from each site (minimum 0, maximum 60)  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Location (text) Sent to laboratory for:  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Cytology  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Pathology  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Microbiology  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Specimens labeled and documented (Labels to be generated by above information) Media Documentation video of  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  #  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Disposition  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  To patient  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  To archives  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Documentation photo of  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  #  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Disposition  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET To patient  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  To archives  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  To chart Comments: Therapeutic devices  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Argon plasma coagulator  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Serial #/ Unit ID  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Manufacturer  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Site (pull from specimen list)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Gas Flow (check?)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Watts  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Seconds  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Pulses #  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Watt seconds (multiplication of watts x seconds)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Balloons  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Manufacturer  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Serial #  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Size(s)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  French  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Length  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  PSI (Pounds per square inch)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Time (minutes, seconds)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Bicap hemostasis/heater probe  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Manufacturer  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Serial #  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Probe size  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Coagulation power (0-10)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Watts  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Biopsy forceps  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Hot  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  upper  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  lower  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Cold  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  upper  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  lower  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Both  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Manufacturer  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Identification code  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Number used  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Type (drop down menu per institution)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Capsule  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Signal verified  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Lot #  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Time ingested Cautery  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Manufacturer  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Serial # / Unit ID  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Settings  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Watts  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Monopolar  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Cut (0-10 or range)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Coag (0-10 or range)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Blend (0-10 or range)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Bipolar  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Cut (0-10 or range)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Coag (0-10 or range)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Blend (0-10 or range)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Grounding Pad  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Placement  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Thigh  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  L  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  R  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Other  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Skin preparation  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Yes  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  No  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Not applicable  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Skin condition at pad removal  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Same as preprocedure  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Erythematous  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Abrasion  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Other  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Cytology brush  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Manufacturer  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Identification code  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Number used  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Type (drop down per institution)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Drain/stent  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Type  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Biliary  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Colonic  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Esophageal  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Nasal Biliary  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Pancreatic  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Rectal  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Manufacturer  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Serial #  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  French (customize - pull from inventory) _____cm  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Length  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Dilatation  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Balloons  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Manufacturer  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Serial #  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Size(s)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  French  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Length  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  PSI (Pounds per square inch)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Time (minutes, seconds)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Bougie  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Maloney  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  French (multiple choice per institution, free text)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Hurst  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  French (multiple choice per institution, free text)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Savary  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Millimeters  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  EMR Kit  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Manufacturer  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Serial # / Unit ID  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Site  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Endocut  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Type of probe  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Filter change  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Medications  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Epinephrine  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Normal saline  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  ERCP  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Basket  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Serial #  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  French  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Cannulas  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Serial #  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  French  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Dilation catheter  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET Serial #  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  French  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Papillatome  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Serial #  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  French  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Stone retrieval  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Balloon  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Serial #  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  French  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Foreign body retrieval  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Basket  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Biopsy forceps  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Magnet  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Net  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Rat tooth  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Snare  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Tripod  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Other (free text)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Fine needle aspiration needle  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Manufacturer  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Serial # / Unit ID  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Size  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Guide wires  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Manufacturer  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Serial #  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Size(s)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Number  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Type  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Injection therapy  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Site (from specimen list)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Needle serial #  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Size  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Medications/solutions  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Epinephrine  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Ethanolamine  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  India ink  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Normal saline  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Sodium morruate  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Sodium tetradecyl  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Dilution  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Total amount  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Increments  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Number of injections  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Laser  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Serial # / Unit ID  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Manufacturer  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Site  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Gas Flow (check INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET )  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Joules  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Seconds  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Pulses (#)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Joules Seconds (multiplication of watts times seconds)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Motility/manometry catheter  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Type  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Water perfused  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Solid state  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Placement  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Esophageal  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Location  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  R Nares  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  L Nares  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Oral  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  ___________ cm  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Rectal  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  ___________ cm  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Biliary  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Pancreatic  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Percutaneous endoscopic gastrostomy/jejunostomy  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Manufacturer  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Serial #  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  French (range)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  pH Probe  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Manufacturer  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Serial #  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Unit ID  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Placement  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Location  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  R Nares  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  L Nares  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Oral  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  ___________ cm  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  On medications  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Yes  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  No  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Time probe inserted  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Date probe inserted  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Time probe removed  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Date probe removed  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Snares  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Manufacturer  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Serial #  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Size(s)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Number  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Type  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Spray catheter  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Acetylcysteline  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Lugols solution  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Methylene Blue  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Variceal ligation  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Banding  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  number of bands  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  site  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Standard equipment in room (optional to list) Comments: Sedation monitoring  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Aldrete scoring  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Activity  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Able to move 4 extremities (2)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Able to move 2 extremities (1)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Able to move 0 extremities (0)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Respiration  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Deeply breaths, coughs freely (2)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Dyspnea or limited breathing (1)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Apneic (0)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Circulation  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Systolic BP +/- 20 mmHg pre- procedure level (2)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Systolic BP +/- 20 mmHg to 50 mmHg pre-procedure level (1)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Systolic BP +/- 50 mmHg or more of pre-procedure level (0)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Consciousness  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Fully awake (2)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Arises on Calling (1)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Unresponsive (0)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Color  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Pink (2)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Pale, dusky, blotchy, jaundiced (1)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Cyanotic (0) Patient position(s)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Decubitus  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Fowlers  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Lateral  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Left  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Right  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Prone  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Semi-fowlers  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Supine  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Trendelenburg Oral suction  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Yes  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  No Transportation to recovery room  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Ambulatory  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Wheel chair  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Via stretcher with side rails up Intravenous fluids (have system do the math to give total at end) (match pre-procedure list)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Solution  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  D5/W  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Normal saline  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Lactated ringers  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  D5 1/2 NS  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  D5 1/4 NS  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Packed red blood cells  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Fresh frozen plasma  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Platelets  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Total amount infused  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Site  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Other  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Discontinued time  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Catheter tip intact  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Yes  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  No  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Site with edema  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Yes  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  No  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Site with erythema  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Yes  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  No Medications (computer enter name of administrator/time of administration)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Antibiotics (list most common used per institution)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Bowel prep  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Fleets enema  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  PEG solution  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Interventional medications  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Cholecystokinen  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Glucagon  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Metaclopramide  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Simethicone  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Sedation  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Diphanhydramine  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Droperidol IV  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Fentanyl IV  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Meperidine IV  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Midazolam IV  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Naxolone IV  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Promethazine IV  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Propofol  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Romazicon IV  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Other (free text)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Topical anesthetics  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Benzocaine Spray PO  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Lidocaine viscous  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  2% Lidocaine jelly  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Other medications  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Acetylcysteline  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Atropine  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Epinepherine IV  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Lugols solution  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Lidocaine injectable  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  2%  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  4%  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Methylene Blue  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Sincalide IV  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Free text Radiation (Fluoroscopy)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Patient shielded  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Yes  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  No  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Not applicable  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Fluoroscopy settings  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Contrast media  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Amount  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Type  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Ionic  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Full  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Half  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Non-ionic  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Full  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Half  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Gastrograffin  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Total fluoroscopy time  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Time out of room Comments: POST-PROCEDURE  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Time admitted to recovery Procedure(s) performed (link to procedure(s) scheduled)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Capsule Endoscopy  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Scheduled  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Repeated  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Colonoscopy  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Scheduled  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Repeated  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Emergency  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Dilation  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Scheduled  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Repeated  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Emergency  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  EGD  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Scheduled  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Repeated  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Emergency  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  ERCP  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Scheduled  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Repeated  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Emergency  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  EUS  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET FNA  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Scheduled  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Repeated  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Flexible sigmoidoscopy  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Scheduled  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Repeated  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Emergency  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Manometry and Motility  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Biliary  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Esophageal  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Rectal  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Scheduled  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Repeated  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  24 hour pH  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Scheduled  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Repeated Vital signs  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Blood pressure  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Heart rate  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Heart rhythm  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Respiratory rate  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  O2 saturation  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Capnography (CO2)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Oxygen at ______liters (link from pre-procedure)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Time initiated  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Time discontinued  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET How administered  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Cannula  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Mask  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Tracheostomy  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  ET tube  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Skin temperature  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Warm  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Cool  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Skin status  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Dry  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Moist  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Intact  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Yes  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  No  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Body piercing (free text to indicate location)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Other Additional Tests  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  EKG  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Glucometer  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Blood glucose level  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Time  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Other  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Lab (drop menu with list)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Radiology (drop menu with list) Discharge instructions (be sure JCAHO requirements are covered here) Diet (can choose more than one)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  As tolerated  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Clear liquid  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Full liquid  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Gluten free  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  High fiber  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Low fiber  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Low fat  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Return to normal  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Small frequent meals  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Soft  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Other (free text) Limitations (These are examples customize for individual institution)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Do not drive any vehicle, drink alcohol, operate any dangerous equipment - such as power tools, lawn mowers, etc., or make any major decisions for at least 12 hours.  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Do not eat any solid food for one hour following the completion of the procedure.  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Do not take any aspirin, Advil, Nuprin, Alleve, BC powder, or ibuprofen for 7 days. Tylenol is acceptable.  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Fluids encourage to drink  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Medication instructions  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Prescriptions provided  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Rest at home for the next 12 hours  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Questions invited and answered  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Yes  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET No  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Narrative (text) Follow up appointment  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Office  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Procedure Emergency follow up indicated for: (examples customize for individual facility)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Any gastrointestinal bleeding > 1 tablespoon  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Any pain or red streaks near your IV site  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Nausea or vomiting lasting over 2 hours  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Referred pain to shoulder/neck area  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Severe or unusual abdominal discomfort or pain  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Temperature over 101 degrees F  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Call Dr.  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET immediately at phone #  INCLUDEPICTURE "http://www.sgna.org/mds/txt.gif" \* MERGEFORMATINET  Post procedure teaching  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Date  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Time  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Method  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Verbal  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Video  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Written  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Verbalizes understanding  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Individuals present for teaching  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Patient  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Spouse  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Parent  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Child  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Sibling  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Friend  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Significant other  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Teaching content verbalized as understood by:  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Patient  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Spouse  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Parent  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Child  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Sibling  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Friend  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Significant other  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Potential barriers to learning  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Anxiety level  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Cognitive ability  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Hearing  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Language  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Primary language  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Translator utilized  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Sight  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Teaching content (drop-down menu with common discharge instruction worksheets to identify which one(s) were given to the patient/family/etc.)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  People present for teaching (write in names) Post procedure devices in place (those inserted during procedure)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  ET tube  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  PEG/PEJ  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Rectal tube  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Stent (link to intraprocedure entry) Post procedure devices retrieved  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Discharged with devices in place  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Retrieved prior to discharge  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  ET tube  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  PEG/PEJ  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Rectal tube  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Stent (link to intraprocedure entry) Occurrences  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Admitted to hospital  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Allergic reaction  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Anesthesia  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Aspiration  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Bleeding  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Code  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Flumazemil administration  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Intubation  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  IV infiltration  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Naloxone administration  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Nausea  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Perforation  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Readiness for discharge greater than 2 hours  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Vomiting Comments: Discharge  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Inpatient  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Returned to room  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Admitted to ICU  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Transferred to another facility  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Transported by  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  RN  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  LVN  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Tech  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Other  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Outpatient  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Home  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Admitted to room  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Admitted to ICU  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Returned to ER  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Transferred to another facility  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Accompanied by (specify name)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Family  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Significant other  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Ambulance staff  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Transportation  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Public  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Private  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Mode  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Ambulatory  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Wheel chair  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Stretcher  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Report  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Called  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Given to  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Given by  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Not applicable Assessment  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Abdominal assessment  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Soft  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Firm  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Round  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Flat  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Distended  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Tender  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Nontender  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Ascites  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Passing flatus  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Gag reflex present  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Tolerating PO fluids Intravenous access  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Site(s)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Solution  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  D5/W  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Normal saline  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Lactated ringers  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  D5 1/2 NS  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  D5 1/4 NS  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Packed red blood cells  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Fresh frozen plasma (FFP)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Other  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Total amount infused  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Total amount remaining (system should calculate from amt. hung and amt. infused.)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Discontinued time  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Type of dressing applied  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Catheter tip intact  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Yes  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  No  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Site with edema  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Yes  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Site care instructions offered  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  No  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Site with erythema  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Yes  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Site care instructions offered Aldrete scoring  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Activity  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Able to move 4 extremities (2)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Able to move 2 extremities (1)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Able to move 0 extremities (0)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Respiration  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Deeply breaths, coughs freely (2)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Dyspnea or limited breathing (1)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Apneic (0)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Circulation  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Systolic BP +/- 20 mmHg pre- procedure level (2)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Systolic BP +/- 20 mmHg to 50 mmHg pre-procedure level (1)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Systolic BP +/- 50 mmHg or more of pre-procedure level (0)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Consciousness  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Fully awake (2)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Arises on Calling (1)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Unresponsive (0)  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Color  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Pink (2)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Pale, dusky, blotchy, jaundiced (1)  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Cyanotic (0) Pain  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  No  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Yes  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET Location  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Duration  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  0-10  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  What 0-10 would be acceptable?  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Frequency  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Symptoms relieved by  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Symptoms worsened by  INCLUDEPICTURE "http://www.sgna.org/mds/radio.gif" \* MERGEFORMATINET  Description  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Free text Belongings returned  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Dentures  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Glasses  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Hearing aids  INCLUDEPICTURE "http://www.sgna.org/mds/checkbox.gif" \* MERGEFORMATINET  Other Discharged by: (drop down menu with list of staff) Comments:      Minimum Data Set SGNA Headquarters, 401 North Michigan Avenue, Chicago, IL 60611-4267 800/245-SGNA or 312/321-5165; FAX 312/673-6694; www.sgna.org  YZ[\]^fgno! 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radiob?jk/j>.x{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>z{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>4}{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>:{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdV  S 2AcheckboxbR H܀#.@{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdP  S ,A radiob?jk/j><{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>B{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>Ő{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>H{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>˕{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>N{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>њ{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>T{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>ן{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>Z{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>ݤ{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>`{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP 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HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>~{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdV  S 2AcheckboxbR H܀#.{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.{n& H܀#PNG  IHDR E5N`PLTEQbKGDH 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2AcheckboxbR H܀#.{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdP  S ,A radiob?jk/j>{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C ؉1$Hy4BDarzAڹ,%9+} &Xs4v HbbPcǁ3Oiz>[*IIENDB`DdP  S ,A radiob?jk/j>L{n?jk/j>PNG  IHDR E5NPLTE$Wͫڹ[ndhpмاUz`]!UxbKGDH cmPPJCmp0712HsxIDATWM0 @}C 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H܀#.wz{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.s|{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.o~{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.k{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.g{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.c{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#._{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.[{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.W{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.S{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.O{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.K{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.G{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.C{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.?{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.;{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.7{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#.3{n& H܀#PNG  IHDR E5N`PLTEQbKGDH cmPPJCmp0712HsKIDATWMK0P*H׈שB dh"ASrP vhBqQ@Z5WIENDB`DdV  S 2AcheckboxbR H܀#./{n& 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