Salem Laser and Surgery Center
YAG Laser Iridotomy Flow Sheet / Orders
Advance / Directive:
Patient Name:
Procedure Date:
PRE-OPERATIVE HISTORY
Chief Complaint:
Findings:
Narrow anatomical angles
OD     OS
Other:
Pre-op Diagnosis:
OD    OS
ODOS
Other:
Planned Procedure:
YAG laser Iridotomy
ODOS
Other:
Significant Medical History:
Current Medications and Dosages:



Drug Allergies:
RXN:    
NAUSEA
VOMIT
RASH
SHOCK
OTHER
Signature
Date:
Time: :
REASSESSMENT:       H & P Current and valid. No Changes
Other:
Signature
Date:
Time: :
PRE / INTRA-OP
Admit Time:
BP
P
R
T
Other:
Surgical Safety Checklist Completed   
Medication:
Procedure: YAG laser Iridotomy ODOS
Anesthesia:      
Surgeon:
Millijoules
Pulses
Comments
POST OP
BP P R
Discharged with instructions
Discharge Time:  
Other
Accompanied by: Nurse Notes:
Medications: 1 gtt in:     OD   OS



Post-Operative Summary / Discharge Order
Diagnosis: OD   OS
     OD   OS

Complications:     Other:  


Patient stable on discharge
Other:


RN Signature
Date
Physician Signature
Date
Time

PATIENT LABEL