Blue Procedure Scheduling Form Gastroenterology Specialties Blues Procedure Form *AAPC APPROVED*Patient Name First Last Today's Date Date Format: MM slash DD slash YYYY Medical Record #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 in the past 9 months?* Yes No Are you on dialysis?* Yes No Do you have significant mobility issues? Yes No Have you had an infection such as c.diff, MRSA, or VRSA in the past 12 months?* Yes No 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 any 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 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?*Does the patient speak English?* Yes No REQUEST INTERPRETER* INTERPRETER ACKNOWLEGEMENT Procedure Date Date Format: MM slash DD slash YYYY 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 OutpatientProcedureColonoscopy, Routine - 45378Colonoscopy, Diagnostic - 45378EGD - 43235EGD Dilation - 43450EGD w/EUS - 43235/43259Endoscopic Ultrasound - 43259ERCP - 43260ERCP w/poss Stent/Sphinc - 43262/43274ERCP w/stent removal - 43275Esophageal Dil - 43220Esophageal Motility - 91010Flexible Sigmoidoscopy - 45330Hemorrhoid Banding - 46221Liver Biopsy - 76942PEG Placement - 43246Pouchoscopy - 44385Rectal Ultrasound - 4539124 HR PH study - 91037Anorectal Motility - 91122Withw/Balloon Dil - 43249w/Banding - 43244w/Boxtox Inj - 43236w/Bravo - 43235/43239w/Fluoroscopy - 76000w/Fwd/Sideview scope - 47999w/Halo - 43229/43270w/Poss ERBE - 45388w/Small bowel biopsy - 44361w/Sypglass - 43273Anesthesia MAC Conscious Sedation General Anesthesia Prep OrdersPlenvuHappy ColonSuprepGolytelyDulcolax TabsFleets EnemaMagnesium CitrateMoviprepNulytelySuprepSutabIndicationPhysician Scheduled withDr. AntonsonDr. BowmanDr. CoenDr. GriffinDr. HrnicekDr. KnooihuizenDr. LawtonDr. NewtonDr. PetersenDr. RifeDr. RoatDr. RothDr. SorrellDr. ThomasDr. VanceDr. WellsReferring PhysicianSchedulerRoute to send pre-pro
