Adult Pre-Operative Orders
Orders preceded by a checked box (☑) are in effect unless crossed out. Orders preceded by a box (☐), require a check (✓) to initiate. Orders with blanks indicate additional information is needed.
Date:
Time:  
Allergies:  
Admitting Diagnosis:
ICD-9 Code:  
PATIENT CLASS:                
LEVEL OF CARE:                        
SERVICES:                
Orders below will be assigned a pre-op phase of care unless otherwise noted
Patient Name:
Date of Birth:  
Procedure Scheduled:
Date of Surgery:
Alert Anesthesia Regarding:  
Pre-Admission Testing fo be Completed Prior to Admission
    or
xunits
Other Labs:
or at:
or at:
On Admisstion / Pre-Op
On Admission Labs to be done STAT
   
   
        or    
   
 
DVT Prophylaxis
       
       
Reason:
Genitourinary     *Required Section*
SCIP Compliant Antibiotics for COLON SURGERY in patients NOT ALLERGIC to Beta-Lactams (Choose ONE option only) Dosing by Pharmacy
SCIP Compliant Antibiotics for COLON SURGERY in patients ALLERGIC to Beta-Lactams (Choose ONE option only) Dosing by Pharmacy
SCIP Compliant Antibiotics for HYSTERECTOMY in patients NOT ALLERGIC to Beta-Lactams (Choose ONE option only) Dosing by Pharmacy
SCIP Compliant Antibiotics for HYSTERECTOMY in patients ALLERGIC to Beta-Lactams (Choose ONE option only) Dosing by Pharmacy
Antibiotic Options for All Other (NON-SCIP) Surgeries - Dosing by Pharmacy
Additional Medications:
Pain Management Pre-Operative Medications
Discharge Plan
Please Initial:
Noted
Order entry
First RN      
Date / Time
Date / Time
Date / Time
Second RN
Date / Time
PATIENT LABEL
(VALID ONLY WHEN SIGNED BY PHYSICIAN)