Report •
Q3aPZ020 W26
Patient: Thomas Hochstatter 7 L du7r1 W
DOB: 03/20/1962
MR#: 2246330
DOS: 02/20/2020
GIW DocuSign Workflow
Appointment Date: 03/24/2020
Type of Appointment: DAC/Recall
MyHealthConnection Status
Patient has a MyHealthConnection account.
Patient Email Address: thomashochstatter@gmail.com
[X] Notified patient forms will be sent within 48 hours.
Completed by: Sarah King February 20, 2020 5:31 PM
DocuSign Forms
The following forms have been sent to the patient via DocuSign:
[X] Agreement of Portal Use
[X] DAC/Recall Welcome Letter
[X] Consents, Releases &Agreements
[X] DAC/Recall Packet
[X] Financial Policy
[X] Patient Profile
[X] Procedure Patient History
[X] Release of Verbal Medical Information
[X] Sent Procedure Instructions via: Secure Messaging
Completed by: Sarah King February 20, 2020 5:31 PM
PATIENT APPOINTMENT & PROCEDURE INSTRUCTIONS
PATIENT: Thomas Hochstatter
CHART#: 2246330
APPT DATE: 03/24/2020
ARRIVAL TIME: 9:20 am
PLACE: The Oregon Clinic, Gastroenterology-West, 9701 SW Barnes Rd, Portland OR, 97225
CHECK IN AT: Suite 310
PHYSICIAN: Adam Silverblatt MD
PROCEDURE: Colonoscopy
Sent Secure E-Mail
To: thomashochstatter@gmail.com
SUPREP INSTRUCTIONS: Please read these instructions at least a week before your procedure!
YOU MUST HAVE SOMEONE DRIVE YOU HOME. YOU WILL BE SEDATED FOR YOUR PROCEDURE. YOU SHOULD
NOT DRIVE AGAIN UNTIL THE MORNING AFTER YOUR PROCEDURE.
You may not take a taxi, bus, MAX, or any type of public transportation unless accompanied by an adult. Drivers or adult
companions will be confirmed at the time of check in either in person or by phone, or your procedure will be
rescheduled. Rides must be present no later than 5pm. Please contact the office for specific driver instructions.
Please call our office prior to your procedure if you have had a change in your health, serious "
illness, or have been hospitalized since your last visit.
On the day of your procedure, do not have anything by mouth 4 hours prior to your procedure. This
includes water, mints, gum, hard candies and tobacco.
WHAT YOU WILL NEED:
• SUPREP prescription (to be filled at your pharmacy).
• 4 (Four) Gas-X Extra strength (simethicone 125mg anti-gas)chewables or soft gels (over the
counter).
• Clear liquid diet supplies for a day and a half. (See CLEAR LIQUID DIET Handout.)
• Suggestions: cup with straw and lid for drinking prep, wet wipes, diaper rash ointment. (See the
HELPFUL TIPS FOR PREPARING FOR A COLONOSCOPY Handout.)
PREPARATION:
• FOLLOW ALL INSTRUCTIONS BELOW. DO NOT FOLLOW INSTRUCTIONS INCLUDED IN THE PREP KIT.
• It is important to continue to take all your regularly scheduled prescribed medications while you complete the prep,
up until 4 hours before your procedure, ESPECIALLY BLOOD PRESSURE or HEART medications, ANTI-SEIZURE
meds, and PAIN meds, unless your doctor told you otherwise.
• If your medications are due during the time you are supposed to drink the preparation or if they are due during the last 4 hours
before your procedure, you may need to take them earlier than scheduled. Check with the provider who prescribed them if
you need further instructions.
• If you are diabetic, please refer to the separate instruction sheet for details regarding diabetes medication adjustment and
additional preparation instructions.
Beginning 03/17/2020, which is 7 days prior to your procedure:
1. STOP ALL HERBAL MEDICINES AND SUPPLEMENTS
a. Including but not limited to: Iron, vitamin E, ginger, garlic, valerian root, and fish oil.
b. You may continue to take a multivitamin.
2. STOP EATING VISIBLE NUTS, SEEDS, AND WHOLE GRAINS
a. Examples with visible nuts/seeds/grains: Multi-grain breads and cereals, quinoa, oatmeal, poppy seeds, sesame seeds,
popcorn, nuts, all fruits with visible seeds that cannot be removed (such as berries [blueberries are ok] and
jams/preserves). If you can remove the seeds, you can have foods like tomatoes, cucumbers, melons, apples, oranges,
etc.
3. IF YOU TAKE COUMADIN (warfarin), PLAVIX, OR ANY OTHER BLOOD THINNING MEDICATIONS
a. Please refer to the handout BLOOD THINNING AGENTS for further instructions. Please make
sure you understand if you are supposed to stop taking your blood thinner or not. If you have any
questions, call our office or your prescribing physician.
Beginning 03/23/2020, which is 1 day prior to your procedure:
1. START CLEAR LIQUID DIET (Refer to CLEAR LIQUID DIET Handout for directions and examples)
a. Start when you wake up. No solid foods of any kind the entire day. It is very important to
stay hydrated, so drink frequently throughout the day and drink lots of water, at least 8 glasses.
b. To keep from getting too hungry be sure to include some of the high protein options, and you
need calories, so having some options that are not sugar-free are important, even for diabetics.
c. Remember NO RED or PURPLE liquids! (Could make your colon look'inflamed'.)
d. ABSOLUTELY NO ALCOHOL!
2. At 6:00 pm, START LAXATIVE PREP:
a. Mix and drink 15!half of your prep.
1. Do not drink the solution directly from the bottle. Pour ONE (1) 6-ounce bottle of SUPREP liquid into the
mixing container.
2. Add cool drinking water to the 16-ounce line on the container and mix.
3. Drink ALL the liquid in the container.
4. You MUST drink two (2) more 16-ounce containers of water over the next 1 hour.
b. Take 2 (two) Gas-X (or simethicone)with a small amount of clear liquid.
c. Be prepared, sometimes the prep starts working right away. However, it can take several hours before some people
have their first bowel movement. In either case, be ready to spend a lot of time on the toilet. You may have bowel
movements throughout the night.
d. Continue to drink lots of water and clear liquids of your choice all evening. This is a necessary step to ensure
adequate hydration and an effective prep.
Beginning 03/24/2020, which is the day of your procedure:
1. CONTINUE CLEAR LIQUID DIET AND LAXATIVE PREP
a. Again, no solid foods of any kind before your procedure. Continue clear liquid diet as above.
2. At 4:20 am, which is 6 HOURS PRIOR to your procedure:
a. Mix and drink 2"d half of your prep.
1. Pour second 6-ounce bottle of SUPREP liquid into the mixing container.
2. Add cool drinking water to the 16-ounce line on the container and mix.
3. Drink ALL the liquid in the container.
4. You MUST drink two (2) more 16-ounce containers of water over the next 1 hour.
b. Take 2 (two) Gas-X (or simethicone)with a small amount of clear liquid.
c. Expect another series of bowel movements, which may continue up until you leave home. The output should be
getting clearer until it looks like urine.
d. You may continue to drink clear liquids of your choice up until 4 hours before your scheduled appointment.
e. Be sure you have taken all of your regularly scheduled prescribed medications that are due during the next 4-6 hours.
f. Stop all tobacco products, including chewing tobacco.
HOW DO I KNOW IF MY PREP IS WORKING AFTER DRINKING THE SECOND HALF?
Look at your stool!
Yes, my prep is working if:
• My output is clear(I can see the bottom of the toilet bowl)-yellow and clear like urine
• My output is light orange and almost clear(no solid pieces)
No, my prep may not be good enough so I should call the office if:
• My output is dark or brown and murky (I cannot see the bottom of the toilet bowl)- not clear
• My output is dark orange and somewhat clear.
Your procedure could be rescheduled or delayed if you are not prepped properly. If you are not sure that your prep is working,
please call: (503) 297-8081
3. At 6:20 am, which is 4 HOURS PRIOR to your procedure:
a. Stop drinking ALL liquids and have NOTHING MORE BY MOUTH until after your procedure. This
includes stopping plain water, chewing gum, mints, hard candies, etc.
b. Having fluids in your stomach, even a lot of saliva, puts you at risk for vomiting and possibly inhaling fluid into your lungs
while you are sedated.
c. The only exception: If you have a critical medication that cannot be taken 4-6 hours early, it can be taken up to 2
hours before the procedure, BUT ONLY WITH A SIP OF WATER (no more than 2-3 TABLESPOONS).
d. FOR YOUR SAFETY....Failure to follow this will result in your procedure being cancelled and rescheduled. NO
EXCEPTIONS.
e. REMEMBER: You need to arrive at 9:20am to check in for your procedure.
ADDITIONAL INSTRUCTIONS:
• Female patients: IF YOU ARE PREGNANT OR ARE UNSURE IF YOU ARE PREGNANT: YOUR PROCEDURE MAY BE
CANCELLED WHEN YOU ARRIVE. We strongly recommend you take a pregnancy test if you are unsure. Please call us
before the procedure date to discuss this if you are, or could be, pregnant.
• If you use an inhaler for asthma or COPD, please bring this with you to your procedure.
• Bring your insurance card and a photo ID to your procedure.
• Do not bring valuables to your procedure.
• Friends and family may not watch your procedure.
• For the safety of our patients and staff, we ask that you leave any weapons at home.
• You may be charged a fee for missed appointments that are not cancelled or rescheduled 3 business days prior to your
procedure time. The fees are as follows:
Hospital or Office Procedures $100
Ambulatory Surgery Center $200
•
FOR PATIENTS' PRIVACY CELL PHONES AND OTHER ELECTRONIC DEVICES MUST BE POWERED OFF AND
STORED AWAY WHILE IN THE PROCEDURE AREA. PHOTOGRAPHS AND RECORDINGS ARE PROHIBITED.
Clear Liquid Diet
For: Thomas Hochstatter
Purpose:
A clear liquid diet consists of clear liquids that are easily digested and leave no undigested residue in your intestinal tract. This is
why a clear liquid diet must be followed before a procedure. Not following the diet correctly can affect the prep results and the
ability to view your intestinal tract.
Definition:
Clear liquids are those that one can see through with no solids or pulp. When a clear liquid is in a container such as a bowl or
glass, the container is visible through the substance. Although not "clear", black coffee/tea and sodas like Coke are ok on a clear
liquid diet.
Clear liquids and foods (gelatin) may be colored so long as you are able to see through them. Avoid anything that is colored
RED or PURPLE. Look for CLEAR, YELLOW, BLUE, GREEN OR ORANGE flavors (PINK is OK, too); examples: lemon, lime,
orange, apple, white grape, peach, banana, blue raspberry. (The only exception is the clear protein drinks, as described below.)
Tips when following a clear liquid diet:
• You need to stay hydrated, especially if taking a colonoscopy prep! Drink lots of water!
• Buy lots of different options so you can have a variety to choose from.
• Drink frequently throughout the day to keep from getting too hungry.
• Drinking high protein options are especially important.
• You need calories, so having some options that are not sugar-free are important, even for diabetics.
• ABSOLUTELY NO ALCOHOL!
Examples/Shopping List:
• Clear vegetable, chicken, and beef broth/bouillon, or consommé. [High protein options]
• Clear protein drinks
o Available at many grocery and drug stores and online.
o NOTE: If you can only locate red or purple options, it is okay to drink a limited amount but no more than two
bottles per 24 hours, preferably diluted with other clear fluids, like club soda, Sprite/7-Up, sparkling water, etc.
• Flavored gelatin/Jell-O (without fruit)and gummy bears
• Clear sports drinks (Gatorade, Powerade, Propel, etc.)
• Pedialyte
• Clear juices (such as apple or white grape)
• Coffee or tea (without cream or milk)
• Water(plain, seltzer, sparkling, or flavored)
• Coconut water(no pulp or mixtures with non-clear juices)
• Soft drinks (soda/pop)
• Crystal Light -optional (can also be used to flavor your prep)
• Italian ice, plain popsicles/ice pops (no pureed fruit or fiber, no sherbet or gelato)
• Hard candies, lollipops, menthol cough drops (Tip: these are helpful to use between glasses of prep!)
Electronically signed by Sarah King on 02/20/2020 at 05:31:39 PM