Log Title: OBRES Gynecologic Case Log
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1 Log Title: OBRES Gynecologic Case Log Hospital/Institution: (Lookup) Attending Physician (Lookup) Is Patient Pregnant? ( Y or N) MEDRECNO: (text) Date (encounter) (Date) Diagnosis DX GYN Acute Pelvic Pain Abnormal Uterine Bleeding Adnexal Mass AGUS Anovulatory Uterine Bleeding ASCUS Breast Disease Chronic Pelvic Pain Complete Family Status Diabetes Dysfunctional Uterine Bleeding Dysmenorrhea Ectopic Pregnancy Endometriosis Stage Hypertension, Essential Infertility Interstitial Cystitis Leiomyomata Menometrorrhagia Menorrhagia Metrorrhagia Ovarian Mass/Cysts PAP Non specific ABN Pelvic Inflammatory Disease Pelvic Mass Pelvic Organ Prolapse Postmenopausal Bleeding Rectocele Urinary Incontinence Uterine Fibroid Vaginal Lesion Vulvar Lesion DX OB Updated: 9/11/2013 Pg.1 of 13
2 Abortion, Complete Abortion, Elective Abortion, Habitual Abortion, Incomplete Abortion, Missed Aneuploidy Anomaly, CNS Anomaly, Non CNS Breech Cervical Insufficiency Cesarean Section, Elective Cesarean Section, Previous Diabetes, Gestational (A1&A2) Diabetes, Pre existing Dystocia of Labor Eclampsia HELLP Syndrome Hypertension, Chronic Hypertension, Gestational IUFD IUGR IUP Non reassuring fetal status Non VBAC Candidate Placenta Abruptio Placenta Accreta Placenta Previa PROM PPROM Pre Eclampsia, Mild Pre Eclampsia, Severe Pre Eclampsia, Superimposed Pregnancy, Di di Twin Pregnancy, Mono di Twin Pregnancy, Mono mono Twin Pregnancy, Triplet Preterm Labor SROM Updated: 9/11/2013 Pg.2 of 13
3 DX ONC Breast Carcinoma Cervical Carcinoma Endometrial Carcinoma Fallopian Tube Carcinoma Gestational Trophoblastic Neoplasia Ovarian Carcinoma Vaginal Carcinoma Vulvar Carcinoma Diagnosis Other: (text) Case Comments: (text) Abdomen 1. Appendectomy a. Laparotomy Surgeon b. Laparotomy Assist c. Laparoscopy Surgeon d. Laparoscopy Assist 2. Cytoreduction: (New) 3. Intraperitoneal Catheter Placement (new) a. Laparotomy Surgeon b. Laparotomy Assist c. Laparoscopy Surgeon d. Laparoscopy Assist 4. Laparoscopy Diagnostic 5. Laparoscopy, Operative a. Laser Surgeon b. Laser Assist c. Lysis of Adhesions Surgeon d. Dest. of Endo. Implants Surg e. Dest. of Endo. Implants Assi f. Other Surgeon g. Other Assist 6. Laparotomy, Exploratory Updated: 9/11/2013 Pg.3 of 13
4 7. Lysis of Adhesions, abdominal 8. Multiple Peritoneal Biopsies: (New) 9. Omentectomy (New) 10. Pelvic Lymphadenectomy 11. Pelvic Mass Removal: (New) 12. Periaortic Lymphadenectomy (New) Bladder, Urologic 1. Cystoscopy 2. Repair Of Bladder Lacerations Updated: 9/11/2013 Pg.4 of 13
5 3. Stents 4. Ureterolysis (New) 5. Urethrovesical Suspension, Laparoscopic 6. Urethrovesical Suspension, Transabdominal a. BURCH Surgeon b. BURCH Assist c. MMK Surgeon d. MMK Assist e. Stamey Surgeon f. Stamey Assist g. w/graft 7. Urethrovesical Suspension, Transvaginal a. Retropubic Surgeon b. Retropubic Assist c. Transobturator Surgeon d. Transobturator Assist 8. Bladder, Urologic Other Bowel 1. Colostomy, Laparotomy 2. Enterotomy: (New) 3. Ileo cecal resection, Laparotomy (New) 4. Ileostomy, Laparotomy (New) Updated: 9/11/2013 Pg.5 of 13
6 5. Proctoscopy: (New) 6. Recto sigmoid resection, Laparotomy (New) 7. Small bowel resection, Laparotomy (New) 8. Bowel, "Other" Breast 1. Breast Biopsy 2. Puncture Aspir. Breast Cyst 3. Breast "Other" Cervix 1. Colposcopy 2. Conization Of Cervix a. LEEP Surgeon b. LEEP Assist c. Cold Knife Surgeon d. Cold Knife Assist e. Laser Surgeon f. Laser Assist 3. Cryocautery, Initial/Repeat 4. Exam Under Anesthesia (Stage Cervical Cancer) (New) 5. Excision or Destruction of Lesion or tissue of the Cervix c. Other Surgeon 6. Trachelectomy Updated: 9/11/2013 Pg.6 of 13
7 c. Laparotomy Robot Surgeon d. Laparotomy Robot Assist 7. Cervix Other Fallopian Tubes 1. Destruction Or Occlusion Of Fallopian Tubes (not associated with birth) a. Laparotomy Surgeon b. Laparotomy Assist c. Laparoscopy Surgeon a. Laparoscopy Assist b. Hysteroscopy Surgeon c. Hysteroscopy Assist 2. Hysterosalpingogram 3. Repair Of Fallopian Tube 4. Salpingectomy 5. Salpingotomy 6. Tubal Dye Perfusion 7. Other Ovary 1. Aspiration Of Ovary Updated: 9/11/2013 Pg.7 of 13
8 2. Lysis Of Adhesions Of Ovary 3. Oophorectomy (Unilateral or Bilateral) Not associated with Hysterectomy 4. Ovarian Biopsy 5. Ovarian Cystectomy 6. Para Oophoron Cyst f. Laparoscopy Robot Assist 7. Release Of Torsion Of Ovary Updated: 9/11/2013 Pg.8 of 13
9 8. Repair Of Ovary 9. Salpingo Oophorectomy (Unilateral or Bilateral) Not associated with Hysterectomy 10. Wedge Resection Of Ovary 11. Other Uterus 1. Abortion a. D&E Surgeon b. D&E Assist c. D&C Suction Surgeon d. D&C Suction Assist 2. D&C (Dilation And Curettage) 3. Endometrial Ablation a. Hysteroscopy Surgeon b. Hysteroscopy Assist c. Non Hysteroscopic Surgeon d. Non Hysteroscopic Assist 4. Endometrial Biopsy 5. Hysterectomy, Radical Abdominal Updated: 9/11/2013 Pg.9 of 13
10 b. Laparotomy Assist c. Laparotomy Robot Surgeon d. Laparotomy Robot Assist e. W/Ovaries 6. Hysterectomy, Subtotal a. Abdominal Surgeon b. Abdominal Assist c. Laparoscopic Surgeon d. Laparoscopic Assist e. Robotic Surgeon f. Robotic Assist g. w/ovaries 7. Hysterectomy, Total a. Abdominal Surgeon b. Abdominal Assist c. Laparoscopic Surgeon d. Laparoscopic Assist e. Vaginal Surgeon f. Vaginal Assist g. LAVH (Laparoscopic Assisted Vaginal Hysterectomy) Surgeon h. LAVH Assist i. Robotic Surgeon j. Robotic Assist k. w/ovaries 8. Hysteroscopy, Diagnostic 9. Hysteroscopy, Operative a. Lysis of Adhesion Surgeon b. Lysis of Adhesion Assist c. Myomectomy Surgeon d. Myomectomy Assist e. Resection of Septum Surgeon f. Resection of Septum Assist g. Polypectomy Surgeon h. Polypectomy Assist 10. Hysterotomy 11. Myomectomy Updated: 9/11/2013 Pg.10 of 13
11 12. Pelvic Exenteration, Anterior 13. Pelvic Exenteration, Posterior 14. Pelvic Exenteration, Total 15. Uterine Repair 16. Other Ultrasound, GYN, (Hospital or Clinic NOT associated with birth):) a. GYN Vaginal Probe Surgeon b. GYN Abdominal Probe Surgeon Vagina and Cul De Sac 1. Colpotomy 2. Destruction Of Vaginal Lesion a. Laser Surgeon b. Laser Assist c. Other Surgeon d. Other Assist 3. Obliteration And Total Excision Of The Vagina 4. Repair Of Cystocele c. w/graft 5. Repair Of Enterocele c. w/graft 6. Repair of fistula a. Rectovaginal Surgeon b. Rectovaginal Assist c. Vesicovaginal Surgeon d. Vesicovaginal Assist e. w/graft f. Other Surgeon Updated: 9/11/2013 Pg.11 of 13
12 g. Other Assist 7. Repair Of Rectocele c. w/graft 8. Repair Of Vaginal Lacerations (Not associated with birth) 9. Vaginal Biopsy 10. Vaginal Suspension a. Abdominal Surgeon b. Abdominal Assist c. Vaginal Surgeon d. Vaginal Assist e. Sacrospinous Surgeon f. Sacrospinous Assist g. w/graft h. Other Surgeon i. Other Assist 11. Vaginal Other Vulva and Perineum 1. Destruction Of Vulvar Lesions a. Laser Surgeon b. Laser Assist c. Other Surgeon d. Other Assist 2. Inguinal Lymphadenectomy 3. Operations On Bartholin s Gland a. Marsupialization Surgeon b. Marsupialization Assist c. Bartholinectomy Surgeon d. Bartholinectomy Assist 4. Perineum, Biopsy 5. Repair Of Perineal Lacerations Not associated with birth 6. Vulvar Biopsy Updated: 9/11/2013 Pg.12 of 13
13 7. Vulvectomy a. Radical Surgeon b. Radical Assist c. Simple Surgeon d. Simple Assist 8. Vulva and Perineum Other OMM/OMT 1. OMM/OMT performed a. Clinic b. Hospital Updated: 9/11/2013 Pg.13 of 13
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