Vascular and Interventional Radiology

Pre-procedure Note – Sample Template

Pt Name:                                                                      Medical Record Number:

Age:                                                                             Location:

Procedure Requested:                                                    Requesting Physician:

History of Present Illness:

symptoms now requiring treatment (reason for procedure), prior Interventional Radiology procedures, when NPO

Past Medical/Surgical History:

System Review:

? Pregnant (document LMP)

Bleeding Disorder

Hypercoagulable State

Renal Failure: Etiology

Cardiac History: Hypertension/MI/Arrhythmia

Diabetes

Smoking: Pack Years/Currently Smoking

Asthma/COPD (i.e. emphysema)

ENT (h/o TMJ Problems)

TIA/Stroke: Etiology

Medications and Allergies:

Physical Exam:

General (must document if patient is alert and oriented)

Heart

Lung

Abdomen

Neuro-Sensory-Motor (esp. for patients undergoing carotid arteriography, carotid stenting and thrombolytic therapy)

Extremities

Pulses (0= non-Dopplerable; D = Dopplerable; 1 = weak; 2 = normal; 3 = aneurysmal):

Radial               Brachial            Femoral            Popliteal            PT                    DP

R

L

Skin changes:

Labs:

BUN/creatinine; INR; wbc, hgb/hct, platelet (& other pertinent, e.g. LFTs)

Prior Non-invasive Imaging Studies

Type/Date/Results

Assessment:

Plan (must include):

1.       anticipated procedure(s)

2.       consent obtained from __________________

Conscious sedation may be required for patient comfort