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Discipline

: Surgery

Sub Discipline

: Surgery

Document Title

: Procedure Note Endoscopic Ultrasound

PROCEDURE DETAILS

Procedure Ordered

Procedure Requested By

Date & Time Of Procedure

From

To

PERFORMING STAFF

Performing Staff

Indication[S]

Please Update Method

PRE-SCOPE HISTORY

Previous EUS

YesNoneNot known

Findings

Concomitant Medical Conditions

YesNoneNot known

Bronchial Asthma

COAD

Ischemic Heart Disease (IHD)

Hypertension

Diabetes

Vulvular Heart Disease

Prosthetic Cardiac Valve

Immunocompromised

Others, specify

Risk Factors

AntiHCV

Current Medication

YesNoneUnknown

Antibiotics

Comments

MEDICATION ADMINISTERED

Premedication

YesNo

Babcon/Simethicone Liquid

Sedation

YesNo

Comments

GA

YesNo

Intubated

Comments

Smooth Muscle Relaxant

YesNo

Comments

Antidote/ Reversal

YesNo

Comments

Antibiotic Prophylaxis

YesNo

Comments

PROCEDURE REPORT

Image

Endoscopic Ultrasonography (Eus)

Diagnostic

YesNo

Staging Of Tumours

YesNo

Therapeutic

YesNo

DIAGNOSIS

Endoscopic Impression

Post-procedure Instructions

Follow-Up Plan

SIGNATURES

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