Northbank Surgical Center
Physician's Order Sheet

Patient Name:

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

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

Xanax PO per standing order on admission if local
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 - LIDS     Rev. 7/06
(PATIENT LABEL)