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> PDT Documentation Checklist
PDT Documentation Checklist
Patient Information
Patient name
Date of birth
Medical record number
Allergies
Current medications
Past medical history
Procedure Information
Date and time of procedure
Procedure performed
Physician performing procedure
Anesthesia used
Complications during procedure
Documentation
Informed consent signed
Pre-procedure evaluation completed
Post-procedure evaluation completed
Procedure notes completed
Discharge instructions given
Follow-up
Follow-up appointments scheduled
Lab work or imaging ordered
Medication changes made
Referrals given
Quality Assurance
Documentation reviewed for accuracy
Any discrepancies addressed
Feedback provided to staff
Documentation filed appropriately
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