Physician's Order Sheet
Patient Name:
PRE-OPERATIVE ORDERS
1.
Diagnosis:            
Mild/Moderate Glaucoma-        
2.
Procedure:   
   
       
       
3.
Admit to Northbank Surgical Center
4.
Check Medication Reconciliation sheet for allergies.
5.
Routine admitting vital signs
6.
Anesthesiologist to evaluate patient if MAC
7.
Start saline lock. May use lidocaine 2%, 0.1 to 0.2 ml for local anesthesia for insertion of IV needle.
8.
Place H&P in chart.
9.
PRE-OP MEDICATIONS:
  1.     Proparacaine 0.5% ophthalmic solution, 1-3 drops in operative eye PRN.
  2.     Give 1 drop of Compounded DILATING ophthalmic solution [contents below] in operative eye;
        repeat in 10 minutes PRN:
        -Tropicamide 1%
        -Phenylephrine 2.5%
        -Cyclopentolate 1%
        -Ketorolac 0.5%
  3.     Give 0.5mg Versed IVP on call to OR.
10.
Check blood glucose level preoperatively on all insulin dependent patients.
11.
If lists, and/or patient reports EVER using an alpha adrenergic medication, give Atropine Sulfate 1% ophthalmic solution, 1 drop in operative eye; repeat in 5 minutes.
12.
Other
INTRA-OPERATIVE ORDERS
1.
Routine per preference card
2.
Other
POST-OP APPOINTMENT:
Date:
Time:
Signature
MD
Date:
Time:


PHYSICIAN ORDER SHEET       Rev. 06/17
(PATIENT LABEL)