Salem Laser and Surgery Center
Physician's Order Sheet

Patient Name:

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

Diagnosis:
  1.   Admit to Salem Laser and Surgery 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.

b.

c.
Xanax PO per standing order on admission if local
Proparacaine 0.5%   1-3 gtts prn

Cyclogyl 1%
Neosynephrine 10%
Ocufen 0.03%
Proparacaine 0.5%








Per pledget protocol on admission; may use gtt protocol if unable to place pledget

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)