Chronic Venous Disease Evaluation Note (Varicose Veins)

Date: [Date]

Patient: [Patient name / MRN]

Encounter Type: [new / follow-up]; [in-person / telehealth]

Reason for Visit: Chronic venous disease evaluation / varicose veins

Referring Provider: [Name / None]

Records Reviewed: [List of prior duplex reports, operative notes, wound care records with dates] (If none, state "None.")

Chief Complaint

[Primary venous complaint with laterality] (One concise line capturing the primary venous complaint with laterality. Avoid additional background here.)

History of Present Illness

[Narrative HPI] (Begin with the chief complaint. Then concisely include: laterality and anatomic distribution of varicosities; venous symptoms such as aching, heaviness, fatigue, swelling, itching, burning, cramping, restless sensation, skin irritation, bleeding, superficial thrombophlebitis; severity, onset, progression, diurnal pattern; aggravating factors such as standing/sitting and relieving factors such as elevation/compression; functional impact on work, ambulation, sleep, ADLs including missed work or inability to stand for required durations; prior venous interventions with dates and outcomes; DVT/PE history with provoking factors; relevant risk factors including pregnancies, hormone therapy, family history, obesity, occupational standing, limb trauma/surgery. If prior duplex was performed elsewhere, note date and whether report and/or images were reviewed. Keep to one cohesive paragraph.)

Conservative Management History

(This section supports medical necessity. Specify what was tried, the duration, and outcomes. Never state "failed conservative therapy" without details.)

Compression therapy: Type: [knee-high / thigh-high / pantyhose / wrap / other]; Strength: [mmHg]; Frequency: [hours/day and days/week]; Duration: [trial duration]; Tolerance: [tolerated / not tolerated due to pain / dermatitis / difficulty donning / other]; Response: [improved / no change / worsened] (If not used, document reason.)

Lifestyle measures: Elevation: [frequency and perceived benefit]; Exercise/walking: [type and frequency]; Weight management: [efforts and progress if applicable]

Other treatments: [Analgesics, topical therapies for dermatitis, wound care history if ulcer present] (List specific agents and duration if applicable. If no other treatments, state "None.")

(If conservative measures have not been tried, explicitly document reason.)

Past Medical/Surgical History

[Relevant medical and surgical history] (Focus on conditions affecting diagnosis or procedural candidacy: PAD, CHF, CKD, liver disease, diabetes, active cancer, hypercoagulable disorders, prior VTE with dates and provoking factors, prior venous or limb surgeries/procedures.)

Medications

[Current medication list] (Explicitly note anticoagulants/antiplatelets, hormone therapy, diuretics, analgesics.)

Allergies

[Drug and non-drug allergies] (Include adhesives, sclerosants, compression material sensitivities if applicable.)

Social History

Tobacco: [never / former / current; quantity and duration]

Occupation: [Role and standing requirements]

Mobility: [independent / assistive device / limited]

Constraints affecting recovery or compression adherence: [Details if applicable]

Family History

[Family history of varicose veins, venous ulcers, VTE] (State "None" or "Unknown" if not available.)

Review of Systems

(Target the venous presentation and differentials; keep brief.)

• Cardiovascular: [Dyspnea, orthopnea, chest pain, palpitations]
• Renal/Hepatic: [Edema-related symptoms, ascites, urinary changes]
• Neurologic: [Numbness, weakness, neuropathy symptoms]
• Musculoskeletal: [Joint pain, limb pain not vascular in nature]
• Infectious: [Fever, chills, cellulitis signs]
• Dermatologic: [Pruritus, dermatitis, skin changes]

Physical Examination

Vitals/General: BP [BP]; HR [HR]; RR [RR]; Temp [Temp]; Height [Height]; Weight [Weight]; BMI [BMI]. General appearance: [general appearance]. Gait/mobility: [gait and mobility].

Arterial: Pedal pulses: DP R [0 / 1+ / 2+], PT R [0 / 1+ / 2+]; DP L [0 / 1+ / 2+], PT L [0 / 1+ / 2+]. Capillary refill: [normal / delayed]. Temperature: [warm / cool]. (Note if ABI is known or ordered if arterial concern exists.)

Venous Examination - Right Leg

• Varicosities: Location: [thigh / calf / ankle]; Caliber: [small / moderate / large]; Tenderness: [present / absent]
• Telangiectasias/reticular veins: [present / absent; location]
• Edema: Severity: [none / mild / moderate / severe]; Pitting: [grade]; Distribution: [ankle / calf / thigh]
• Skin changes: [pigmentation / eczema / lipodermatosclerosis / atrophie blanche / none]
• Ulcers: [Location, size, wound characteristics] (Omit if none.)
• Superficial thrombophlebitis signs: [palpable cord / erythema / warmth / none]

Venous Examination - Left Leg

• Varicosities: Location: [thigh / calf / ankle]; Caliber: [small / moderate / large]; Tenderness: [present / absent]
• Telangiectasias/reticular veins: [present / absent; location]
• Edema: Severity: [none / mild / moderate / severe]; Pitting: [grade]; Distribution: [ankle / calf / thigh]
• Skin changes: [pigmentation / eczema / lipodermatosclerosis / atrophie blanche / none]
• Ulcers: [Location, size, wound characteristics] (Omit if none.)
• Superficial thrombophlebitis signs: [palpable cord / erythema / warmth / none]

Duplex Ultrasound Findings

(Include this section only if duplex venous reflux study has been performed and results are available. If duplex is ordered but pending, state only: "Duplex venous reflux study ordered; results pending." Do not infer reflux patterns or duration without duplex evidence. If duplex was not performed, omit this entire section.)

Study Information: Date: [Date]; Facility: [Facility]; Patient position: [standing / reverse Trendelenburg / supine]; Provocation: [Valsalva / distal augmentation / other]; Review: [official report reviewed / images independently reviewed / both]

Right Leg Findings

• Deep system: Patency: [patent / occluded]; Compressibility: [compressible / non-compressible]; Reflux: [present / absent; duration]; Post-thrombotic changes: [present / absent]
• Superficial system: SFJ: [competent / incompetent]; GSV reflux: [none / junctional / axial / segmental]; Duration: [seconds]; Diameter: [mm at specified location]. SSV/SPJ: [findings]. Accessory saphenous veins: [findings if evaluated]
• Perforators: [Location, diameter, outward flow duration if pathologic] (Omit if none identified.)
• Thrombus: DVT: [present / absent]; SVT: [location and extent if present]

Left Leg Findings

• Deep system: Patency: [patent / occluded]; Compressibility: [compressible / non-compressible]; Reflux: [present / absent; duration]; Post-thrombotic changes: [present / absent]
• Superficial system: SFJ: [competent / incompetent]; GSV reflux: [none / junctional / axial / segmental]; Duration: [seconds]; Diameter: [mm at specified location]. SSV/SPJ: [findings]. Accessory saphenous veins: [findings if evaluated]
• Perforators: [Location, diameter, outward flow duration if pathologic] (Omit if none identified.)
• Thrombus: DVT: [present / absent]; SVT: [location and extent if present]

Duplex Interpretation: [Summary of dominant reflux source(s), correlation with symptoms and visible varicosities, whether anatomy supports endovenous treatment, findings that alter management such as deep obstruction or acute thrombosis]

Classification and Severity Scoring

Right Leg:

• CEAP: C[0s-6], E[p/s/c/n], A[s/d/p/n], P[r/o/r,o/n] (Mark any axis as "undetermined" if it cannot be assigned. Do not assign clinical class without corresponding exam findings.)
• VCSS: [Total score] (Note if incomplete and why.)

Left Leg:

• CEAP: C[0s-6], E[p/s/c/n], A[s/d/p/n], P[r/o/r,o/n]
• VCSS: [Total score]

Assessment

1. Chronic venous disease / varicose veins: [Laterality, CEAP clinical class, duplex correlation if available] (Summarize how exam and duplex support diagnosis and symptoms.)
2. Venous complications: [Venous edema, stasis dermatitis, hyperpigmentation, lipodermatosclerosis, healed venous ulcer, active venous ulcer, bleeding varicosities, superficial thrombophlebitis] (Include only items present. Omit if none.)
3. Differential diagnoses: [Lymphedema, cardiac edema, renal/hepatic edema, PAD, neuropathy, musculoskeletal causes] (Include only if symptoms are not fully explained by venous findings; state what additional evaluation is planned.)

Plan

Patient Goals and Preferences: [Symptom relief / edema control / ulcer healing or prevention / cosmesis]; Patient preference: [conservative management / procedural intervention / undecided]

Conservative Management

• Compression: [Strength mmHg]; [Style: knee-high / thigh-high / pantyhose / wrap]; [Wear schedule]; [Donning aid if needed]
• Lifestyle: [Elevation schedule]; [Exercise/walking plan]; [Weight management if applicable]
• Skin/Ulcer care: [Dermatitis regimen, ulcer care plan, wound care referral if applicable] (Omit if not applicable.)
• Return precautions: Bleeding, new or worsening ulceration, sudden swelling/pain, signs of thrombophlebitis

Interventional Candidacy

Candidate for intervention: [Yes / No / Pending duplex / Pending conservative trial]

(If "No," document reason: pregnancy, arterial disease concern, acute thrombosis, unsuitable anatomy, patient preference, other.)

Medical Necessity Summary: (Include if intervention is considered.) [Documented symptoms and functional impact] + [Conservative measures tried with duration and outcomes or reason for intolerance] + [Duplex-confirmed reflux pattern with treatable target]

Proposed Procedure Plan

(Include only if patient is a candidate for intervention.)

• Right leg: Target: [GSV / SSV / accessory / tributaries]; Modality: [thermal ablation / non-thermal ablation / phlebectomy / sclerotherapy]; Tributary management: [simultaneous / staged]; Rationale: [rationale]
• Left leg: Target: [GSV / SSV / accessory / tributaries]; Modality: [thermal ablation / non-thermal ablation / phlebectomy / sclerotherapy]; Tributary management: [simultaneous / staged]; Rationale: [rationale]

Contraindications/Precautions: [Pregnancy timing, arterial disease, hypercoagulable state, inability to ambulate or tolerate post-procedure compression, anatomic limitations, anticoagulation considerations] (Omit if none.)

Risk/Benefit/Alternatives Discussion: Benefits: [symptom relief, edema improvement, ulcer risk reduction]. Risks: [thrombosis, nerve injury, skin changes, phlebitis, recurrence, need for additional procedures]. Alternatives: [continued conservative care, different procedural options, no treatment].

Orders

• [Duplex venous reflux study with laterality and clinical question] (Omit if already completed.)
• [Compression stocking prescription: strength, style, quantity]
• [ABI or other vascular testing if arterial concern]
• [Labs or referrals as indicated]

Follow-up: [Interval and purpose] (If conservative trial planned, specify duration constituting an adequate trial. If awaiting studies, specify result review plan.)