Northbank Surgical Center
Physician's Order Sheet

Patient Name:

PRE-OPERATIVE ORDERS
Allergies/Reactions:   or list below:

Diagnosis:
  1.   Admit to Northbank Surgical Center
  2.   Routine admitting vital signs
  3.   Anethesiologist to evaluate if MAC
  4.   Saline lock started
  5.   H & P on chart
  6.   PRE-OP MEDICATIONS


a.


Neosynephrine 10%
Ocufen 0.03%
Proparacaine 0.5%





Per drop protocol on admission;
1 gtt every 5 min x 3

7.
Check serum glucose level if on medication for diabetes
8.
Other:

INTRA-OPERATIVE ORDERS
  1.   Routine per preference card
  2.   Other:
                 

POST-OP APPOINTMENT:       Date:   Time:

Signature MD
Date:
Time:

PHYSICIAN ORDER SHEET - GENERAL OPHTH       5/07
(PATIENT LABEL)