Northbank Laser Flow Sheet / Orders
PRE-OPERATIVE HISTORY
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:
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
REASSESSMENT: H & P Current and valid. No Changes
Surgical Safety Checklist Time out with verification of procedure/site complete
RN Signature
Date
Physician Signature
Date
Time