Procedure Flow Sheet - Cooled Thermotherapy

Cooled ThermoTherapy™ Procedure Flow Sheet

Name:

Date:

Physician:

PRE-PROCEDURE CHECKLIST

Allergies:

Consent Signed:

Enema:

Routine Medications:

Cysto: _____

IPSS: _____

QMax: _____

PSA: _____

Prostate Size: _____

PUL: ______

Pre-Procedure Vital Signs:

B/P ________ P ________

Temp ________

Loc: _______

Pre-Medication Time

Pre-Medication Time

INTRA PROCEDURE

Time In: _______ Time Out: _______

Treatment Start: ________

Treatment End: ________

Time

B/P

P

R

O2 Sat

Medications

Time

MDS S/N ________________________

RTU Lot # _______________________

Treatment Time ___________________

POST PROCEDURE

Post Therapy Catheter:

LOC:

Discharge Vital Signs:

Catheter Removal:

Return Appointment:

Discharge Medications:

Discharge Instructions Given by:

Nurse Signature:

MD Signature:

TM

Cooled ThermoTherapy

is available by prescription only. This therapy is not for everyone. Talk to your physician to see if Cooled ThermoTherapy is right for you.

Most medical procedures may have side effects. Possible side effects for Cooled ThermoTherapy

include blood in urine, clots in urine, painful or difficult urination,

thickened bladder muscle, rectal irritation, temporary inability to control urination, brief inability to achieve or maintain an erection and the inability to discharge semen in

orgasm thus should be considered by men who wish to have further offspring. A small risk of urethral stricture may result requiring further intervention. Patients may

experience discomfort during the procedure that may require the use of analgesics or sedatives. Patients may be catheterized for a 2 to 5 day period following the

1

treatment.

For more complete information about the benefits and risks associated with Cooled ThermoTherapy please refer to the Instructions for Use found on our

website at

or call us at 1.800.475.1403.

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Data taken from the CTC Advance® Instructions for Use, 250348 Rev B 12/08.

MC1286 Rev C 05/09