Blue Form New Gastroenterology Specialties Blues Procedure Form (New) Patient Name(Required) First Last Date Medical Record #(Required)Referring PhysicianHeight FTHeight InchesWeight lbsBMIPatient BMI OK to schedule at LEC Acknowledged NO LEC, Patient BMI ok for LDHC if not a smoker(Required) LDHC acknowledgment HOSPITAL ONLY! Patient can only be scheduled at the Hospital because of BMI(Required) Hospital Acknowledgment On Oxygen(Required) Yes No Liters of Oxygen (# only)Patient OK to schedule at LEC LEC Acknowledgement NO LEC, Patient ok for LDHC if not a smoker(Required) LDHC acknowledgment HOSPITAL ONLY! Patient can only be scheduled at the Hospital(Required) Hospital Acknowledgment Have you had a heart attack, heart bypass or stent in the past 6 months?(Required) Yes No Do you have a defibrillator?(Required) Yes No Have you had a stroke or TIA in the past 9 months?(Required) Yes No FACILITY RESTRICTIONS - SEE TIMELINES BELOW(Required) Stroke less than 4 months ago - SCHEDULE AT HOSPITAL ONLY Stroke 4-9 months ago - SCHEDULE LDHC OR HOSPITAL Are you on dialysis?(Required) Yes No Do you have significant mobility issues? Yes No Please indicate mobility assist used(Required) 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?(Required) Yes No Which do you have?(Required) C.diff MRSA VRSA Do you have Alpha Gal Syndrome (AGS) due to a tick bite?(Required) Yes No Are you allergic to Latex?(Required) Yes No Type of reaction to Latex?(Required) Anaphylaxis Other HOSPITAL ONLY! Patient can only be scheduled at the Hospital(Required) Hospital Acknowledgment Females: Are you currently pregnant? Yes No Do you take any blood thinning medications?(Required) Yes No Name of blood thinning medication and who prescribes it?(Required)SCHEDULE 7 BUSINESS DAYS OUT BECAUSE OF BLOOD THINNING MEDICATION!(Required) SCHEDULE 7 DAYS OUT ACKNOWLEDGEMENT Do you take a once weekly injection for Diabetes for weight loss (GLP1)?(Required) Yes No SCHEDULED 10 BUSINESS DAYS OUT BECAUSE OF ONCE WEEKLY INJECTABLE MEDICATION(Required) SCHEDULE 10 DAYS OUT ACKNOWLEDGEMENT Do you take a SGLT2 medication (commonly used for diabetes, chronic heart failure, or chronic kidney disease)?(Required) Yes No Unknown SCHEDULE 5 BUSINESS DAYS OUT BECAUSE OF GLP2 MEDICATION(Required) SCHEDULE 5 DAYS OUT ACKNOWLEDGEMENT Do you take ORAL prescription weight loss medications?(Required) Yes No Name of weight loss medication and who prescribes it?(Required)SCHEDULE 1 WEEK FOR ALL WEIGHT LOSS MEDICATIONS EXCEPT ORAL GLP-1!(Required) SCHEDULE 1 WEEK OUT ACKNOWLEDGEMENT. Oral GLP1 only held the AM of procedure Do you take Naltrexone?(Required) Yes No SCHEDULE AT LEAST 3 BUSINESS DAYS OUT BECAUSE OF NALTREXONE.(Required) SCHEDULE 3 DAYS OUT ACKNOWLEDGMENT Have you had a prior colonoscopy elsewhere?(Required) Yes No What year was your last Colonoscopy and what was the location?(Required)Is the patient in a facility?(Required) Yes No Name of Facility?(Required)SNF/MCR PATIENTS AT HOSPITAL ONLY! Skillled Nursing facility patients with MCR can only be scheduled at a Hospital.(Required) Hospital Acknowledgement Special NeedsDoes the patient speak English?(Required) Yes No Language(Required)REQUEST INTERPRETER INTERPRETER ACKNOWLEDGEMENT Procedure Date(Required) Is the procedure date within 30 days of an appt? Yes No Was procedure ordered at the appt?(Required) Yes No Nurse to send pre-pro to(Required)Arrival Time(Required)Procedure Time(Required)Procedure Location(Required)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(Required)Colonoscopy, Routine - 45378Colonoscopy, Diagnostic - 45378Colon & EGD - 45378/43235EGD - 43235EGD/Flex Sig - 43235/45330EGD w/ HDR (brachytherapy) - 43241EGD for Capsule placement - 91110EGD w/ esophageal stent exchange - 43266EGD w /EUS - 43235/43259EGD w/ IGB (intragastric balloon placement) - 43235, 43290EGD/Pouchoscopy - 43235/44385EGD w/ TORe - C9785Endoscopic Ultrasound - 43259ESG - 43889EUS/ERCP - 43259/43260EUS/colon - 43259/45378ERCP - 43260ERCP w/ poss Stent/Sphinc - 43262/43274ERCP w/ stent removal - 43260/43275ERCP w/ stent exchange - 43260/43276Esophageal Dilation - 43220Esophageal Motility - 91010Flexible Sigmoidoscopy - 45330Hemorrhoid Banding - 46221Ileoscopy - 44382Liver Biopsy - 76942PEG Placement - 43246Pouchoscopy - 44385Rectal Ultrasound - 4539124 HR PH study - 91037Anorectal Motility - 91122Withw/ APC or RFA ablation (via EGD) - 43270w/ Dilation - 43248, 43249, 43450w/ Banding - 43244w/ Botox Inj - 43236w/ Bravo - 43239, 91035w/ FMT - 45378, 44705w/ Fluoroscopy - 76000w/ Fwd/Sideview scope - 47999w/ Halo - 43229, 43270w/ Liver Biopsy (no additional code)w/ APC/ERBE (via colonoscopy) - 45388w/ Push Enteroscopy - 44360w/ Rectal EUS - 45341w/ Small bowel biopsy - 44361w/ Sypglass - 43273Procedure Time Allotment(Required)20 minutes30 minutes40 minutes50 minutes60 minutes90 minutes120 minutesAnesthesia(Required) MAC Conscious Sedation General Anesthesia No Sedation Prep OrdersPlenvuHappy ColonSuprepGolytelyDulcolax TabsFleets EnemaMagnesium CitrateFleets enema / Magnesium CitrateMoviprepNulytelySuprepSutabModified 2 Day PrepFull 2-Day Prep3 Day PrepMODIFIED PREP, if ordered M2D prep F2D prep Indication(Required)Physician Scheduled with(Required)Dr. AntonsonDr. BowmanDr. GriffinDr. HrnicekDr. KnooihuizenDr. LarsonDr. LawtonDr. NewtonDr. PetersenDr. PrausDr. RifeDr. RoatDr. RothDr. SorrellDr. ThomasDr. VanceDr. WellsScheduler(Required)
