308 lines
7.5 KiB
Plaintext
308 lines
7.5 KiB
Plaintext
English French Notes Complete/Exclude
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ENVIRONMENT CHECK:
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Before initialization, this routine will verify whether the
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package file entries have been converted to the NEW PERSON file.
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OK, there aren't any unconverted pointers.
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Hit <RETURN> to continue
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OK, stopping the installation here..nothing changed!
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*
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* This pre-initialization routine will
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DATA DICTIONARIES
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the data) for the *
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* following files: *
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* 690 (MEDICAL PATIENT) *
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* 691.1 (CARDIAC CATHETERIZATION) *
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* 697.5 (MEDICAL DIAGNOSIS/ICD CODES) *
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* 699.6 (DIAG/THERAP INTERVENT) *
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save any local modifications to the *
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* data dictionaries for these files before *
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* proceeding with this routine. *
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* (See the Installation Guide for instructions.) *
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* Any changes not saved will be
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LOST!
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*
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to abort the installation here, or RETURN to continue
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DATA DICTIONARIES
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for the following *
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* 697.3 (MEDICINE SCREEN) *
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* data dictionaries and data for this file *
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* before proceeding with this routine. *
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DIAGNOSIS ENTRY
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Do you wish to enter this diagnosis as the primary diagnosis
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Enter Primary Diagnosis (1-
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Enter Number of Diagnosis That You Wish to Use as Primary Diagnosis
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Hit Return if you do not wish to enter any of above
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Enter Number of Secondary Diagnosis or 'ALL' to enter all:
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Enter Number of Diagnosis from above list or enter 'ALL' for All Diagnoses to be entered as a secondary diagnosis.
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Possible
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Diagnoses are:
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NON-ENDO
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Select Patient Name or Date/Time of Appointment:
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INSERTION OF STENT
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DILATION BY SAVARY BOUGIE
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GASTROSTOMY TUBE INSERTED
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JEJUNOSTOMY TUBE INSERTED
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HEATER PROBE COAGULATION
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ENTER DATE/TIME OF CONSULT:
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Enter Date/Time of Procedure:
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PERSONAL HISTORY INFORMATION
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History of Bleeding Disorder:
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Valvular Heart Disease:
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Glaucoma:
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History Comments:
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Do you wish to edit the Personal History Information
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The valid Anatomy locations are:
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* END * Press return to continue:
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Enter Date/Time of Non-Endoscopic Procedure:
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Allergies/Adverse Reactions:
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MCAR(690,
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GENERIC EDIT
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GEN.IMPL.
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GENERATOR IMPLANT
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V-LEAD IMP
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VENTRICAL LEAD IMPLANT
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A-LEAD IMP
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ATRIAL LEAD IMPLANT
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DEMOGRAPHIC INFORMATION *** SCREEN EDIT ***
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PROCEDURES *** SCREEN EDIT ***
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Enter patient name, or date and time:
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Select Patient or Date/Time of Endoscopic Procedure:
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Select Patient or Date/Time of Non-Endoscopic Procedure:
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Select Patient or Date/Time of Consultation:
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NON-ENDOSCOPIC
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MC*
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SYMPTOM:
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Type of Cough:
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Duration:
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Location of Pneumonia:
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Dates:
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SURVEILLANCE:
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DISEASE FOLLOWUP:
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FOLLOWUP DEVICE/THERAPY:
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INDICATED THERAPY:
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EGD SIMPLE PRIMARY EXAM
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LAB OR XRAY
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OCCULT BLOOD
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SPECIMEN COLLECTION
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Preparation Diet:
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CLEAR LIQUIDS
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Diet Comment:
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Enemas:
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Bowel Preparation:
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Pneumoperitoneum Gas:
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Pressure Control:
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Stent Type:
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Stent Size:
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Stent Length (mm):
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Sphincterotome Used:
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Incision Size:
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SAVARY BOUGIE DIAMETER
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HEATER PROBE DURATION
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HEATER PROBE POWER
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HEMATOLOGY REPORT
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Hematology Report
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NOT INPATIENT
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Press return to continue, '^' to escape:
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,MCY:DTIME S:'$T MCY=U S:MCY=U DN=0,MCOUT=1 D:DN HEAD^MCARP K MCY
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Methanol
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Ethanol
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Formalin
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GROSS DESCRIPTION: The specimen consisted of
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mm, submitted in
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This specimen is submitted for decalcification in EDTA.
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Part of the specimen is fixed and submitted for processing in plastic.
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BIOPSY COMMENTS:
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Report Released for Printing.
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----------------------------------ATRIAL STUDY----------------------------------
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PREMEDICATION:
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ENTRY SITE:
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RECORDING SITE:
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ATRIAL THRESHOLD (mA):
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CONDUCTION TIMES
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SINUS NODE FUNCTION STUDIES
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PA (NL 20-40 MSEC):
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SACT (NL 80 +/- 40 MSEC):
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AH (NL 60-120 MSEC):
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CSART (NL 260+/- 95 MSEC):
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HV (NL 35-55 MSEC):
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ATRIAL EXTRA STIMULUS TECHNIQUE (VALUES BELOW IN MSEC)
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DRIVE CYCLE LENGTH:
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AERP:
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AVERP:
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HPERP:
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AFRP:
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AVFRP:
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HPFRP:
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ARRP:
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AVRRP:
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HPRRP:
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INCREMENTAL ATRIAL PACING
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MAXIMUM 1:1 CONDUCTION:
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WENCKE CYCLE LENGTH:
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TACHYCARDIA WINDOW:
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RATE:
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MORPHOLOGY:
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CONDUCTION:
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ARRHYTHMIA:
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SHORTEST R-R A FIB:
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SHORTEST R-R POST ISPUREL:
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LOCATION OF TRACT:
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ANTEGRADE ERP
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RETROGRADE ERP
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BYPASS TRACT:
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BYPASS ISUPREL:
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ATRIAL CYCLE LENGTH (MSEC):
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VENT CYCLE LENGTH (MSEC):
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QRS DURATION:
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QRS AXIS:
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QT:
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QTC:
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RYHTHM:
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INTERPRETATION:
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DISCHARGE DATE:
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MEDICATIONS ON DISCHARGE:
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WARD/CLINIC:
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REF HOSP OR PHYS:
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CATH NO:
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HT IN:
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WT LBS:
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PROCEDURES:
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HISTORY:
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SYMPTOMS INCLUDED:
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RISK FACTORS:
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HEART MEDS:
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PHYSICAL:
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PREMEDICATIONS:
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VASCULAR ACCESS:
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CATHETERS:
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TYPE AND SIZE
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RIGHT HEART
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LEFT HEART
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RIGHT CORONARY
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LEFT CORONARY
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FLOURO TIME:
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OTHER PROCEDURE AND COMMENT:
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TECH COMMENTS:
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INTERVENTION:
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PRESSURES:
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RA A:
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PCW A:
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AO S:
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RV S:
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LA A:
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LV S:
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PRE A:
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PA S:
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(POST DYE)
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SATURATIONS:
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RA:
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PA:
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LV:
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IVC:
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RV:
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LA:
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SVC:
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OUTPUT AND INDEX
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ASSUMED FICK
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A V AREA (CM SQ):
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RIGHT CORONARY ARTERY:
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FROM:
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TO:
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LEFT MAIN CA:
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LAD:
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CIRCUMFLEX:
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BYPASS GRAFTS ?:
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DISTAL ANASTOMOSIS:
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WALL MOTION:
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EJECTION FRACTION:
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MITRAL REGURGITATION:
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COMPLICATIONS:
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IMPRESSION:
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CONCLUSION:
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PLAN:
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CARDIOLOGY FELLOW:
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CARDIOLOGY FELLOW (2nd):
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CARDIOLOGY STAFF:
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CARDIOLOGY STAFF (2nd):
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TEST RESULTS:
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% FRACT SHORT:
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LV MASS:
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EF:
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mm Hg
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FINDINGS:
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DIAGNOSIS(ES):
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OTHER CONCLUSIONS:
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CARDIOLOGY ATTENDING:
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CARDIOLOGY FELLOW:
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PROCEDURE SUMMARY:
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ARRHYTHMIA DIAGNOSIS:
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CARDIAC DIAGNOSIS:
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REASON FOR STUDY:
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SYMPTOMS:
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HX:
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RHYTHM:
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RESPONSE TO ATROPINE:
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RESPONSE TO EXERCISE:
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RESPONSE TO CAROTID MASSAGE:
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HEART MEDICATIONS:
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SVT TYPE:
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INTERPRETATION:
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FOLLOW UP:
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CARDIOLOGY FELLOW (2ND)
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Endoscopist:
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FELLOW:
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2ND FELLOW:
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Liver Biopsy:
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Bleeding Disorder:
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Allergies:
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Comments:
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COMMENT:
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Where Performed:
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Start - End:
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Instrument:
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Insertion Depth:
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Medications Used:
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Technique:
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Results:
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Disposition:
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Primary:
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Supplement:
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Instructions:
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PHYSICIANS' SIGNATURE ____________________________________
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Provider/Physician:
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Consultation Type:
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Subjective:
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Objective:
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Assessment:
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Planned:
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Indication Comment:
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Procedure Summary:
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INDICATION:
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MEDICATIONS:
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PROVIDER/PHYSICIAN:
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TECHNIQUE:
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SUBJECTIVE:
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OBJECTIVE:
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ASSESSMENT/FINDINGS:
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PLAN:
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SUMMARY:
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PROCEDURE SUMMARY:
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Consulting Doctor:
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Consultation Type:
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Subjective:
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Allergies/Adverse Reactions:
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Urgency:
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Instrument:
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Physician:
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Follow-up Date:
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REVIEWED BY:
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HOURS:
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MALFUNCTIONS:
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HEART RATE
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TOTAL BEATS
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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