Bronchoscopy booking checklist

Bronchoscopy request.

Patient name and NHS number: []
Date of birth: []
Contact telephone number: []
Referring consultant: []
Indication and clinical question: []
Relevant imaging, with date and where it can be viewed: []
Target [lobe and segment, or lesion location]
Procedures requested: [inspection, washings, brushings, endobronchial biopsy,
transbronchial biopsy, EBUS with stations, cryobiopsy]
Samples required: [microbiology including mycobacteria, cytology, histology,
molecular and PD-L1 testing, lymphocyte subsets]

Safety:
Anticoagulant or antiplatelet: [drug, indication, last dose, plan for
stopping and restarting]
Bleeding history or known coagulopathy: []
Platelets and INR if relevant: []
Renal function: []
Diabetes and treatment, including insulin and GLP-1 agonists: []
Ischaemic heart disease, recent acute coronary syndrome or stroke: []
Baseline SpO2 and oxygen requirement: []
Known difficult airway, or previous problem with sedation: []
High risk of tuberculosis or other transmissible respiratory infection: []
Pregnancy: []
Weight and BMI: []

Practical:
Mobility and whether a hoist is needed: []
Interpreter required, and language: []
Advocacy or capacity considerations, and who holds a welfare power of
attorney: []
Hospital transport needed: []
Escort home available, and where they will be discharged to: []
Inpatient or outpatient: []

For requests from another organisation:
Referring hospital and department: []
Address and GP details: []
Who should receive the report: []