ࡱ> gif @ bjbjPP 0f::@ @ @ @ $d *l!!!!!!!!;*=*=*=*=*=*=*$X,R.Da*"!!""a*!!v*""""!!;*"";*""#%,%!`! P@ "O%%*0*W%,.".%.%4!"!"!!!!!a*a*$@ "@  UPPER GI ENDOSCOPY PROCEDURE DESCRIPTION Method of Wm. MacMillan Rodney, M.D., FAAFP, FACEP For Quality, Please fill-out all items. Original Version 1986(Updated 02-12-02) HYPERLINK "http://www.psot.com"www.psot.com [KEYWORDS: PROCEDURES, EGD, FORMS] Patients Name:____________________________________ Location:_________________________ Age:_______________ Date:____________________________ Sex: M or F Physician:_________________________ Race: B W Hisp Other Assistant(s):_______________________ Pertinent patient history (illnesses, medicines, surgery, allergies, duration of problem:_________________________ ____________________________________________________________________________________________ Has the patient completed 7-10 days of medical therapy (e.g. Axid, Zantac, Prilosec, H2 Blocker, Antacids, etc.?) Yes or No Circle the drug and dosage schedule used: AxidTagametCarafateAny Proton Pump Inhibitor (Prilosec Prevacid, etc.)AntibioticZantacOther H2 BlockerAntacidCytotecIndications: (circle the number of those that apply) SignsICD-9 CodesPre-Existing ConditionsICD-9 Codes1.Abdominal mass789.316.Cancer surveillance in high-risk patients (eg. Barretts Disease, polyposisV67.92.Anemia, unexplained285.917.Esophageal stricture530.33.GI bleeding, gross578.918.Gastric retention536.84.GI bleeding, occult 578.119.History of Duodenitis or Esophagitis or Gastritis or Hiatal HerniaV12.75.X-ray abnormality793.4Symptoms20.Monitoring a gastric ulcer531.906.Dyspepsia, severe536.822.Peptic ulcer disease (PUD) 533.907.Dysphagia/odynophagia787.223.Pyloroduodenal stenosis537.08.Epigastric pain789.024.Varices (bleeding)456.09.Food sticking787.225.Varices (not bleeding)456.110.Heartburn, meal related787.126.Any other indications (please describe below)11.Indigestion, severe536.812.Nausea, chronic (vomiting)787.013.Pain (substernal/paraxiphoid)786.5114.Reflux of food (regurgitation)787.015.Weight loss, severe783.21Before you begin, list the 3 most likely diagnoses you expect to find: 1.__________________________ 2._______________________________ 3.__________________________ Medications Used: (circle drugs used and give total dosage used) 1. Demerol3. Versed5. Other_____Reversal Antidotes2. Romazicon2. Valium4. Fentanyl6. None1. Naloxone3. None -2- Findings: (circle one for each question) 1. Was esophagus well visualized? 1. Yes or No 2. Was pylorus well visualized? 2. Yes or No 3. Was duodenum entered? 3. Yes or No 4. Was Papilla of Vater seen? 4. Yes or No 5. Did you do a turnaround maneuver to see cardia/fundus? 5. Yes or No Pathology Code: (Use this to fill-out the area) 1. Mild erythemia, patchy, no ulcers 3. Severe erythema, limited focal mucosal degeneration (ie, 1-3 ulcers are seen) 2. Moderate erythema, diffuse in areas, some 4. Severe erythema with diffuse mucosal degeneration (more than 3 ulcers) some petechiae, no ulcers are present 5. Other (polyps, cancer, atrophy, or miscellaneous) Circle one inflammation code for each area (see immediately above): Esophagus None 1 2 3 4 5 Antrum/Pylorus None 1 2 3 4 5 Gastric (Rugae)area None 1 2 3 4 5 Duodenum None 1 2 3 4 5 Number of biopsies taken (circle one) 0 1 2 3 4 5 6 7 8 9 10 More Describe pathology (location, size):__________________________________________________________ CLO test performed for the presence of H. pylori? Positive Negative Not Done Serology test sent for confirmation of the presence of H. pylori? Positive Negative Not Done PLEASE ASK YOUR STAFF TO COPY US WITH PATH RESULTS What is your post endoscopy working diagnosis? (circle those that apply) ICD-9 Code ICD-9 Code ICD-9 Code 1. Normal 5. Varices 456.0 9. Ulcer(s) 533.90 2. Esophagitis 530.10 6. Duodenitis 535.60 10. AV malformation 447.0 3. Hiatal hernia 553.3 7. Gastritis 535.40 11. Other (describe)_________ 4. Tumor, growth 151.9 8. Polyp(s) 235.2 ______________________ Will you or did you order UGI x-rays or barium swallow to confirm and/or complement your endoscopy findings? (circle one) Yes or No Were there any complications? (circle one) Yes or No Did this procedure change your management plan? (circle one) Yes or No Comments--Describe how the management plan or diagnosis changed: (circle those that apply) 1. New diagnosis 5. Endoscopy consult not necessary now 8. Diagnostic tests added or deleted 2. Medication added/deleted 6. Suspected diagnosis now confirmed 9. Other (describe)_____________ 3. Medication will be continued 7. Previous diagnosis deleted __________________________ 4. Consultation will be requested Exam performed as above: Signature:______________________________________, M.D. Please check to see that all items have been completed. Complete information strengthens the ability to document high quality care. Thanks for reading. 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