Welcome to MGH Gastroenterology Associates! Dear Patient, At MGH Gastroenterology Associates our goal is to welcome each patient to our practice and ensure they receive the very best care. Our collaborative practice of gastroenterologists, researchers, nurses and staff are dedicated to the prevention, diagnosis, treatment and management of digestive diseases. Possessing expertise in all aspects of digestive health, our multidisciplinary team of specialists offers patients the benefit of an individualized treatment plan. Our scheduling team invests a significant amount of time in coordinating your appointments. Missed appointments and late cancellations can pose problems for our office and may have possible health risks for you the patient, as well as for other patients who could have been seen if the appointment was made available. If you cannot make your scheduled appointment, please call our office to reschedule at least 5 days in advance so that we may accommodate other patients. Also, please note that you must have an adult escort to take you home following your exam. You will not be permitted to drive, and it is essential for your safety that you have an adult escort to take you home. Thank you for choosing Massachusetts General Hospital. We look forward to caring for you. Sincerely, MGH Gastroenterology Associates Did You Know? Colorectal cancer is the 3 rd most common type of cancer (excluding skin cancer) in men and women. For the average person, the lifetime risk of developing colorectal cancer is about 1 in 20 people (5%). This risk can be higher for people with certain risk factors. When found early, colorectal cancer is treatable and beatable. If everyone age 50 or older had a screening test, as many as 90% of deaths from colorectal cancer could be prevented.
GI Procedure Information: Appointment Time and Location Scheduled Procedure: Patient Name: Date and Arrival Time: Physician and Phone Number: Blake Building, 4 th Floor 55 Fruit Street, Boston, MA 02114 Parking: Fruit Street Garage or Parkman Street Garage Charles River Plaza, 9 th Floor 165 Cambridge St, Boston, MA 02114 Parking: Charles River Parking Garage 207 Cambridge Street or Fruit Street Garage or Parkman Street Garage Mass. General/North Shore 102-04 Endicott St., Danvers, MA 01923 Parking: Center for Outpatient Care Included in this Packet Pre-Procedure Checklist Preparation Instructions Medication and Medical History Form Consent to Procedure sample All prescriptions for laxatives have been sent electronically to your preferred pharmacy Contact Information If you have any questions, please contact your GI physician s office directly. It is very important that you keep this appointment. If you must cancel, please do so at least 5 days in advance. Please visit our website www.massgeneral.org/endoscopy for additional information and frequently asked questions.
Directions from Parking to Endoscopy Center For driving directions and more information, please visit the Parking & Visitor Information website at www.massgeneral.org/visit If you are using GPS, please be sure to verify the Zip Code Blake Building, 4th Floor 55 Fruit Street, Boston, MA 02114 From the Fruit Street Garage or Parkman Street Garage After parking, enter through the MGH Main entrance Take the E elevator to the 4th floor of the Blake Building Once you exit the elevator, look for the glass door labeled MGH GI Associates Charles River Plaza, 9th Floor 165 Cambridge Street, Boston, MA 02114 From the Charles River Plaza Parking Garage, 207 Cambridge Street (preferred parking location) Look for the orange wall labeled 165 Cambridge Street Take the elevator to the 9th floor The entrance will be on your left From the Fruit Street Garage or Parkman Street Garages Walk down North Grove Street, take a left onto Cambridge Street Walk 2 ½ blocks and you will see the sign for Charles River Plaza on your left The 165 Cambridge St. building will be on the right of the plaza -enter through the glass doors Elevators are at the end of the hallway, go to the 9th floor -the entrance will be on your left Mass General / North Shore 102-104 Endicott Street, Danvers, MA 01923 From the Center for Outpatient Care Parking Lot Enter through the Main Entrance Elevators straight Ahead Take Elevator to the 2 nd Floor
MGH Gastroenterology Associates 55 Fruit Street Boston, MA 02114-2696 Pre-Procedure Checklist: Anesthesia Procedures IMPORTANT- Please read these instructions at least 2 weeks before your examination and, please set up a Partners HealthCare Patient Gateway account, if you do not have one already. Pre-Procedure Checklist Open a Patient Gateway account at massgeneral.org/mypatientgateway to update your medical record and to improve communication with your care team. o Please make sure to log into your Patient Gateway account to complete your Pre-Procedure Evaluation (PPE) Questionnaire at least 2 days prior to your procedure. Complete the Medication and Medical History Form. Update your MGH registration information by calling 866-211-6588. Call your medical insurance company for a referral if required by your insurance plan. Medications If you have diabetes and are instructed to not eat before the exam, ask your primary care physician about changes in the proper dose of diabetes medications: if you take insulin, we usually recommend you take ½ your normal dose the day of your exam. If you take blood thinners (Coumadin, Plavix, Pradaxa, Lovenox, etc.) we recommend you continue unless you have specifically been asked to stop by the GI physician performing your exam. Transportation Arrange for an adult escort to take you home following your exam. You will not be permitted to drive and it is essential for your safety that you have an adult escort to take you home. If you do not have an adult escort, hospital policy requires us to cancel and reschedule your endoscopy procedure. What to Bring to Your Endoscopy Exam Completed Medication and Medical History Form Name and phone number of your escort if they cannot be with you when you check-in: they should be available to pick you up within 30 minutes of being called. Bring photo identification but do not wear jewelry other than wedding rings. After Your Endoscopy In most cases, you will spend approximately 3 hours in the Endoscopy Unit. We make every effort to perform your exam at the scheduled time but medical care can result in unavoidable delays. Revised 10/2016
MGH Gastroenterology Associates 55 Fruit Street Boston, MA 02114-2696 Colonoscopy Bowel Preparation Instructions NuLYTELY, GoLYTELY, CoLyte or TriLyte (all are equivalent) IMPORTANT- Please Read these Instructions at Least 5 Days Before Your Colonoscopy Five (5) Days Before Your Colonoscopy No raw fruits and raw vegetables for 5 days before the colonoscopy. Well cooked fruits and vegetables are acceptable. Purchase the prescription laxative (but do not mix with water). Colon Cancer Screenings Save Lives Purchase a simethicone anti-gas product (Gas-X, Mylanta Gas, Maalox Anti- Gas, etc.). If you move your bowels two times per week or less or use a laxative more than twice a month, purchase milk of magnesia. Stop iron supplements, vitamins and liquid antacids 5 days before your colonoscopy. Complete the Medication and Medical History Form. Review Patient Consent to Procedure. You do not need to sign the sample consent form. Two (2) Days Before Your Colonoscopy If you move your bowels two times per week or less or, use a laxative more than twice a month, take 4 tablespoons of milk of magnesia at bedtime. One (1) Day Before Your Colonoscopy Begin a clear liquid diet. Clear liquids include any liquid that you can see through. Examples are water, tea, black coffee, clear broth, apple juice, white grape juice, sodas, sports drinks such as Gatorade and Jell-O. Do not consume any solid foods or dairy products until after your colonoscopy. Do not consume anything colored red. Revised 2/2016
If you have diabetes, make appropriate adjustments in your insulin or other diabetic medications as recommended by your primary care doctor. Avoid all alcoholic beverages. Remain well-hydrated by drinking at least 8 ounces (one cup) of clear liquid every hour between 10 am and 5 pm. At 4 pm, mix the NuLYTELY (or equivalent) preparation with water as directed on the container. If a flavor pack was provided and you wish to use it, add it to the container. Lemon flavored Crystal Light can also be used to flavor the preparation. Beginning at 6 pm, drink 8 ounces of the prep solution every 10 minutes until approximately ½ of the prep solution is consumed. Keep drinking the solution on schedule even though the laxative action may not begin for 2-3 hours. If you become nauseated, wait 30 minutes then resume drinking smaller amounts. Drinking the solution through a straw can make it more palatable. Chewing gum or sucking on hard candy between doses can help with the taste of the prep. May use baby wipes if your anal area becomes irritated from frequent bowel movements. At 9 pm, take 2 gas tablets with 8 ounces of clear liquid. The gas tablets reduce bubble formation in your colon and improve the quality of the exam. At 10 pm, take 2 gas tablets with 8 ounces of clear liquid. Day of Your Colonoscopy Take any morning medications with sips of clear liquid at the usual time. 4-5 hours before your scheduled arrival time, drink the remaining prep solution. Drink 8 ounces every 10 minutes until the solution is completely gone. Note that this may require you to awaken very early in the morning in order to complete the prep. Although inconvenient, the correct timing of drinking the prep is critical to obtaining a good colon preparation. Do not eat any food before your exam! You can continue to drink clear liquids until 2 hours before your procedure. Do not chew gum or hard candy within 2 hours of your procedure.
GI Endoscopy Medication and Medical History Form NAME: DOB: Please complete the following worksheet regarding your medications and medical/surgical history. This information will assist the nurse during your admission process. ALLERGIES (Please list) MEDICATION LIST (Please list all medications that you are taking) Name of Medication Dose How often Last taken (date/time) Please list any over-the counter preparations (vitamins, supplements, cold medications, etc) Name of Medication Dose How often Last taken (date/time) Have you ever had any problems with anesthesia or sedation? Yes No Why are you having this procedure today?
GI Endoscopy Medication and Medical History Form Please check the box if you have any of the following medical problems: Gastrointestinal Cardiac Lung Neurological Mental Health Kidney Vascular Orthopedic Blood disorders Immune system Endocrine Cancer Other Have you had any of the following surgical procedures? Abdominal Yes No Pelvic Yes No Heart/Lung Yes No Transplant Yes No Other Yes No Is there anything else you would like us to know?
PATIENT IDENTIFICATION AREA PATIENT CONSENT TO PROCEDURE PATIENT: UNIT NO: PROCEDURE: Right Left Both Sides Not applicable My doctor has told me and I understand what procedure/surgery I am having done. I understand why I need it, the possible risks (like drug reactions, bleeding, infection, and complications from receiving blood or blood components), and that there is no guarantee of results. My doctor has also explained what might happen to me if I don t have this procedure, other choices I can make instead of having this done, (including choosing no treatment) and what can happen to me if I choose to do something else. I understand that with any procedure, problems could come up that we did not expect. My provider explained to me how he/she prevents infections related to my health. The following additional risks or issues were explained to me: If procedural sedation will be used during this procedure to control my pain, I understand that this method of pain control has risks. These risks include diffi culty breathing that may require breathing support and decreased blood pressure. The most common side effects are nausea and vomiting. In rare cases, there can be allergic reactions or cardiac arrest (stopping of the heart). Lastly, I may have pain, even after using these medications. My doctor and/or his/her associates on the Service will perform my procedure/surgery. I understand that Massachusetts General Hospital (MGH) is a teaching hospital. This means that resident doctors, doctors in a medical fellowship (fellows) and students in medical, nursing and related health care professions receive training here, and may take part in my procedure/surgery. A team of medical professionals will work together to perform my procedure/surgery. My doctor or an attending designee will be present for all the critical parts of the procedure/surgery, although other medical professionals may perform some aspects of the procedure as my doctor or the attending designee deems appropriate. I understand that this procedure/surgery may have educational or scientific value. The hospital may photograph, videotape, or record my procedure/surgery for educational, research, quality and other healthcare operations purposes. Any information used for these purposes will not identify me. I understand that blood or other samples removed during this procedure may later be thrown away by MGH. These materials also may be used by MGH, its partners, or affiliates for research, education and other activities that support MGH s mission. I have had the chance to ask questions about the risks, benefits and alternatives to this procedure/surgery. I am happy with the answers I received. I consent to this procedure/surgery. Date Time AM/PM Signature (patient/health care agent/guardian/family member) (If patient s consent cannot be obtained, indicate reason above.) I attest that I discussed all relevant aspects of this procedure/surgery, including the indications, risks, and benefits, as compared with alternative approaches, with the patient, and answered his/her questions. Date Time AM/PM Signature (Physician/Licensed Practitioner) 10465 (10/14)