Patient identification
Next
Next
Diabetes Mellitus
Obstructive sleep apnea
CPAP use
Pulmonary / venous thrombosis
Vitamin deficiency
Metabolic syndrome
Cardiovascular disease
Mental heal condition
Hight blood pressure
Hypothyroidism
GERD
Smoking
Other (relevant disease)
Next
None
Hiatal hernia
Type I
Type II
Type III
Type IV
Esophagitis
LA classification
Grade A
Grade B
Grade C
Grade D
Gastropathy
Peptic ulcer
H. pylori
H. pylori erradicated
Duodenogastric reflux
Next
Planned primary procedure
Alternative procedure
Revision (Previous procedure)
Preop 3D-MDCT/IV-CT
Next
Banana shape
Boot shape
Antrum stapler line distance
Incisura angularis line distance
Cardia stapler line distance
Stapler line oversewing
None
Suture
Other
Calibration
None
Tube
Other
Hiatal plication
None
Yes
Other procedure
Intraoperative adverse events
Leak
Bleeding
Perforation
Stenosis
Other
Treatment
Drain
No
Yes
Intraoperative test
Methylene blue
Endoscopy
Remarkable findings
Prophylaxis
Antibiotic
Antitrombotic
Intermittent pneumatic compression
Next
Major adverse events
None
Yes
Reintervention / endoscopy
Vital signs at discharge
BP:
/
HR:
RR:
Temp:
Drain removal
No drain
Yes (POD)
No, remains in place at discharge date
Next
Postoperative nutritionals recomendations
None
Yes
Verbal
In writing
Both
Send information
Close modal
Ready!
The BP Card of your patient has been submitted successfully
Dowload the BP Card of your patient here
Download PDF
