Blue Procedure Scheduling Form Gastroenterology Specialties Blues Procedure Form "*" indicates required fields *AAPC APPROVED*Patient Name* First Last Today's Date MM slash DD slash YYYY Medical Record #* Referring Physician Height FTHeight InchesWeight lbsBMIPatient BMI OK to schedule at LEC Acknowledged NO LEC, Patient BMI ok for LDHC if not a smoker* LDHC acknowledgement HOSPITAL ONLY! Patient can only be scheduled at the Hospital because of BMI* Hospital Acknowledgement On Oxygen?* Yes No Liters of Oxygen (# only)Patient OK for to schedule at LEC LEC acknowledgement NO LEC, Patient ok for LDHC if not a smoker* LDHC acknowledgement HOSPITAL ONLY! Patient can only be scheduled at the Hospital* Hospital Acknowledgement Have you had a heart attack, heart bypass or stent in the past 6 months?* Yes No Do you have a defibrillator?* Yes No Have you had a stroke or TIA in the past 9 months?* Yes No NO LEC - LDHC or HOSPITAL ONLY* LDHC or HOSPITAL ONLY Acknowledgement Are you on dialysis?* Yes No Do you have significant mobility issues? Yes No Please indicate mobility assist used* Wheelchair Total lift Needs assist to transfer to bed Have you had an infection such as c.diff, MRSA, or VRSA in the past 12 months?* Yes No Which did you have?* C.diff MRSA VRSA Females: Are you currently pregnant? Yes No Are you allergic to Latex?* Yes No Type of reaction to Latex?* Anaphylaxis Other HOSPITAL ONLY! Patient can only be scheduled at the Hospital* Hospital Acknowledgement Do you take any blood thinning medications?* Yes No Name of blood thinning medication and who prescribes it?* SCHEDULE 7 BUSINESS DAYS OUT BECAUSE OF BLOOD THINNING MEDICATION!* SCHEDULE 7 DAYS OUT ACKNOWLEDGEMENT Do you take a once weekly injection for Diabetes or weight loss?* Yes No SCHEDULED 10 BUSINESS DAYS OUT BECAUSE OF ONCE WEEKLY INJECTABLE MEDICATION* SCHEDULE 10 DAYS OUT ACKNOWLEDGEMENT Do you take any ORAL prescription weight loss medications?* Yes No Name of weight loss medication and who prescribes it?* SCHEDULE 2 WEEKS OUT BECAUSE OF WEIGHT LOSS MEDICATION!* SCHEDULE 2 WEEKS OUT ACKNOWLEDGEMENT Do you take Naltrexone?* Yes No SCHEDULE AT LEAST 3 BUSINESS DAYS OUT BECAUSE OF NALTREXONE.* SCHEDULE 3 DAYS OUT ACKNOWLEDGMENT Have you had a prior colonoscopy elsewhere?* Yes No What year was your last Colonoscopy and what was the location?* Is the patient in a facility?* Yes No Name of Facility?* SNF/MCR PATIENTS AT HOSPITAL ONLY! Skillled Nursing facility patients with MCR can only be scheduled at a Hospital.* Hospital Acknowledgement Special Needs Does the patient speak English?* Yes No Language* REQUEST INTERPRETER* INTERPRETER ACKNOWLEGEMENT Procedure Date MM slash DD slash YYYY Is the procedure date within 30 days of an appt? YES NO Was procedure ordered at the appt?* YES NO Nurse to send pre-pro to* Arrival Time* Procedure Time* Procedure Location*Lincoln Endoscopy Center, LLCBryan East OutpatientLincoln Digestive Health Center, LLCBryan West OutpatientSt Elizabeth OutpatientBeatrice Community Hospital OutpatientJefferson Community Health and LifeGrand Island Regional Medical CenterNebraska Heart OutpatientProcedure*Colonoscopy, Routine - 45378Colonoscopy, Diagnostic - 45378Colon & EGD - 45378/43235EGD - 43235EGD/Flex Sig - 43235/45330EGD w/ HDR (brachytherapy) - 43241EDG for Capsule placement - 91110EGD w /EUS - 43235/43259EGD/Pouchoscopy - 43235/44385Endoscopic Ultrasound - 43259EUS/ERCP - 43259/43260EUS/colon - 43259/45378ERCP - 43260ERCP w/ poss Stent/Sphinc - 43262/43274ERCP w/ stent removal - 43275ERCP w/ stent exchange - 43276Esophageal Dilation - 43220Esophageal Motility - 91010Flexible Sigmoidoscopy - 45330Hemorrhoid Banding - 46221Ileoscopy - 44382Liver Biopsy - 76942PEG Placement - 43246Pouchoscopy - 44385Rectal Ultrasound - 4539124 HR PH study - 91037Anorectal Motility - 91122Withw/ Dilation - 43248, 43249, 43450w/ Banding - 43244w/ Botox Inj - 43236w/ Bravo - 43239, 91035w/ FMT - 45378, 44705w/ Fluoroscopy - 76000w/ Fwd/Sideview scope - 47999w/ Halo - 43229, 43270w/ Poss ERBE - 45388w/ Push Enteroscopy - 44360w/ Small bowel biopsy - 44361w/ Sypglass - 43273Procedure Time Allotment*20 minutes30 minutes40 minutes50 minutes60 minutes90 minutes120 minutesAnesthesia* MAC Conscious Sedation General Anesthesia No Sedation Prep OrdersPlenvuHappy ColonSuprepGolytelyDulcolax TabsFleets EnemaMagnesium CitrateFleets enema / Magnesium CitrateMoviprepNulytelySuprepSutabModified 2 Day PrepFull 2-Day Prep3 Day PrepIndication* Physician Scheduled with*Dr. AntonsonDr. BowmanDr. CoenDr. GriffinDr. HrnicekDr. KnooihuizenDr. LawtonDr. NewtonDr. PetersenDr. RifeDr. RoatDr. RothDr. SorrellDr. ThomasDr. VanceDr. WellsScheduler* Untitled Untitled First Choice Second Choice Third Choice Untitled First Choice Second Choice Third Choice
