"Patient Circumcision Intake Form - Newborn Health"

ADVERTISEMENT
ADVERTISEMENT

Download "Patient Circumcision Intake Form - Newborn Health"

Download PDF

Fill PDF online

Rate (4.4 / 5) 5 votes
reset form
Medical Record No.
Physician Use:
Patient Name
EXAMINATION & MANAGEMENT
Birthdate
Physician
Circumcision Intake
Please align patient label to the right
De'id patient
MEDICAL CLEARANCE:
YES NO
Family: history bleeding absent
Height
History obtained from:
Mother _______
Boy:
heart disease absent
Weight
Father _______
GE reflux absent
>5lbs
Other _______
Vitamin K administered
<5lbs
Gestation age at birth
Systems: Constitutional
Abnormalities
Systems: Male Genitourinary
Abnormalities
• Vital signs:
• Testes:
___________________See Chart
_______________Normal
• General appearance:
• Inguinal/hernia:
___________________Normal
_______________Normal
• Epididymis:
_______________Normal
• Anus & perineum:
_______________Normal
May Be
Assessments for Suitability YES
NO
Comments
Unsuited for:
Penis Exam At Bedside
(may push penis base down to induce tumesence)
PENIS SHAFT
click site
length >3cm
Micropenis
of
straight (no chordee)
Chordee
penoscrotal
no torsion (<45° twist)
Penis Torsion
junction
GLANS CORONA
ridge evident
Guides pen mark
SKIN SURFACES
prepuce meatus circumferential
Glans tilt chordee
penopubic crease normal
Buried Penis
penoscrotal junction normal
Push down on
Scrotum Web
scrotum skin confined
PPJ to confirm
Buried Penis
penis/prepuce raphes straight
check for Glans tilt after retract prepuce
Penis Exam After Prepuce Retracted
glans size normal
urethra meatus on glans
glans not tilted
click one choice below
Penis suited to circumcise*
YES
*all clearances & assessments must be "YES"
NO
DIAGNOSIS:
Phimosis (Diagnosis Code: 605)
______________________________
Circumcision or ________________
Plan/Follow-up:
Signature
Date
99242-25
New Patient Consultation
E/M Code:
CEVL for Healthcare, Inc. | http://www.cevlforhealthcare.org
reset form
Medical Record No.
Physician Use:
Patient Name
EXAMINATION & MANAGEMENT
Birthdate
Physician
Circumcision Intake
Please align patient label to the right
De'id patient
MEDICAL CLEARANCE:
YES NO
Family: history bleeding absent
Height
History obtained from:
Mother _______
Boy:
heart disease absent
Weight
Father _______
GE reflux absent
>5lbs
Other _______
Vitamin K administered
<5lbs
Gestation age at birth
Systems: Constitutional
Abnormalities
Systems: Male Genitourinary
Abnormalities
• Vital signs:
• Testes:
___________________See Chart
_______________Normal
• General appearance:
• Inguinal/hernia:
___________________Normal
_______________Normal
• Epididymis:
_______________Normal
• Anus & perineum:
_______________Normal
May Be
Assessments for Suitability YES
NO
Comments
Unsuited for:
Penis Exam At Bedside
(may push penis base down to induce tumesence)
PENIS SHAFT
click site
length >3cm
Micropenis
of
straight (no chordee)
Chordee
penoscrotal
no torsion (<45° twist)
Penis Torsion
junction
GLANS CORONA
ridge evident
Guides pen mark
SKIN SURFACES
prepuce meatus circumferential
Glans tilt chordee
penopubic crease normal
Buried Penis
penoscrotal junction normal
Push down on
Scrotum Web
scrotum skin confined
PPJ to confirm
Buried Penis
penis/prepuce raphes straight
check for Glans tilt after retract prepuce
Penis Exam After Prepuce Retracted
glans size normal
urethra meatus on glans
glans not tilted
click one choice below
Penis suited to circumcise*
YES
*all clearances & assessments must be "YES"
NO
DIAGNOSIS:
Phimosis (Diagnosis Code: 605)
______________________________
Circumcision or ________________
Plan/Follow-up:
Signature
Date
99242-25
New Patient Consultation
E/M Code:
CEVL for Healthcare, Inc. | http://www.cevlforhealthcare.org
Medical Record No.
Physician Use:
Patient Name
EXAMINATION & MANAGEMENT
Birthdate
Physician
about 10days after circumcision
Please align patient label to the right
History obtained from:
Height
Mother _______
Weight
Father _______
Other _______
Systems: Constitutional
Abnormalities
Systems: Male Genitourinary
Abnormalities
• Vital signs:
• Testes:
___________________See Chart
_______________Normal
• General appearance:
• Inguinal/hernia:
___________________Normal
_______________Normal
• Epididymis:
_______________Normal
• Anus & perineum:
_______________Normal
May Be
Assessments for Success
YES
NO
Unsuccessful
Comments
for:
CIRCUMCISION SITE
persistent foreskin
located below corona
circ site unenven
site parallels corona
SKIN SURFACES
penoscrotal junction normal
Buried Penis
GLANS
urethra meatus normal
Hypospadias
click one choice below
Circumcision is successful*
YES
*all assessments must be "YES"
NO
DIAGNOSIS:
Other diagnoses? ______________________
Phimosis (Diagnosis Code: 605)
Plan/Follow-up:
discharge
Other plans?
______________________
E/M Code:
Return Patient visit 99212
Dat
Signature: __________________________________________
CEVL for Healthcare, Inc. | http://www.cevlforhealthcare.org
save this completed form then email PDF
back
Suitability: Penis shaft Length
YES
NO
back
Suitability: Penis shaft straightness
YES
NO
back
Suitability: Penis shaft torsion
YES
NO