Northbank Packet

Scheduler:

Surgeon:

Date & Time Scheduled:

SURGERY DATE:

TIME:

DURATION:

Implants / Supplies needed:

CPT Code(s):

(REQUIRED)

ICD10 Diagnosis Code(s):

(REQUIRED)

RNFA Requested:

Yes / No

Interpreter Required (Physician office or NBSC?):

Yes / No

Overnight (6 hours or more):

Yes / No

X-ray Tech Required

Yes / No

Anesthesia Type:

General

MAC

Conscious Sedation

Local

Patient Name:

Birthdate:

Sex:

M / F

Address:

City:

State:

Zip Code:

BMI:

(Required)

EMPLOYER:

SS#:

FOSTER CHILD:

Yes / No

CASEWORKER NAME:

IF PATIENT IS A MINOR LIST RESPONSIBLE PARENT / GUARDIAN:

Parent Name:

Birthdate:

EMPLOYER:

PRIMARY INSURANCE:

Self-Pay

AUTH #:

Not Required

DATES:

SECONDARY INSURANCE:

DOCTOR SIGNATURE / INITIALS:

Patient Name:

Procedure Date:

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:

is likely to improve patients poor vision

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:

PAR conference done by physician

Drug Allergies:

RXN:

NAUSEA

VOMIT

RASH

SHOCK

OTHER

See Page 2 for additional medications and / or drug allergies

Signature

Date:

Time:

REASSESSMENT: H & P Current and valid. No Changes

Signature

Date:

Time:

Admit Time:

Alert & Oriented:

Other:

BP:

PO2:

Phenylephrine 10% - 1 gtt, 1-2 in operative eye

JCB Lab: Lot #

Exp.

Initial

Time

Brimonidine 0.2% 1gtt Pilocarpine 1% 1 gtt

Normal

Other

Initial

Time

Anesthesia:

None Proparacaine 1% 1 gtt in oper. eye

Heart

Initial

Time

Tetracaine 0.5% 1gtt in oper eye

Lungs

Initial

Time

Tropicamide 0.5% 1gtt in oper eye

Surgical Safety Checklist Time out with verification of procedure/site complete

Procedure: YAG laser posterior capsulotomy OD OS Millijoules Pulses

Yag Start Time:

YAG End Time:

Nurse Notes:

RN Signature:

Date:

POST OP
BP P R PO2
Discharged with instructions
Discharge Time: Ambulatory
Other
Accompanied by:

Rinse operative eye with BSS after laser procedure.

Nurse Notes:

Medications: 1 gtt in: OD OS
Alphagan 0.2%
Betoptic S 0.25%
Other:

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

Complications: None Other:

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

RN Signature

Date

Physician Signature

Date

Time