Northbank Laser Flow Sheet / Orders
Patient Name:
Procedure Date:
PRE-OPERATIVE HISTORY
Chief Complaint:
Patient complains of poor vision in right - left eye(s), and activities of daily living are adversely affected, particularly in the areas of:
reading newsprint-
books-
computer-
distant objects-
street/road signs-
knitting-
sewing-
crocheting:
driving;
recognizing faces;
watching TV;
worsened in bright light;
complains of glare disability:
other:
This surgery:
Findings: OD OS
VA:
BAT:
Other:
Pre-op Diagnosis: OD OS
Other:
Planned Procedure: OD OS
Other:
Significant Medical History:
Previous Cataract Surgery with IOL, OD OS
Current Medications and Dosages:
Drug Allergies:
RXN:    
NAUSEA
VOMIT
RASH
SHOCK
OTHER
Signature
Date:
Time:
REASSESSMENT:       H & P Current and valid. No Changes
Other:
Signature
Date:
Time:
PRE / INTRA-OP
Admit Time:
Other:
BP:
P:
R:
T:
PO2:
Phenylephrine 10% - 1 gtt, 1-2 in operative eye
JCB Lab: Lot #
Exp.
Initial
Time
   
Normal
Other
Initial
Time
Anesthesia:
   
Heart
Initial
Time
Lungs  
Initial
Time
Surgical Safety Checklist Time out with verification of procedure/site complete
Procedure: YAG laser posterior capsulotomy OD OS Millijoules Pulses
Start Time:  
End Time:  
Nurse Notes:
RN Signature:
Date:
POST OP
BP P R PO2
Discharged with instructions
Discharge Time:  
Other
Accompanied by:
Nurse Notes:
Medications: 1 gtt in:     OD   OS




Post-Operative Summary / Discharge Order
Diagnosis: Opacified Posterior lens capsule, OD   OS

Complications:     Other:  

Patient may defer companion on discharge
Patient stable on discharge
Other:

RN Signature
Date
Physician Signature
Date
Time

PATIENT LABEL