Salem Laser and Surgery Center
LASIK Flow Sheet / Orders
Advance / Directive:
Patient Name:
Procedure Date:
PRE-OPERATIVE HISTORY
Chief Complaint: reduced vision due to near-sightedness / far-sightedness / astigmatism
Other:
Pre-op Diagnosis: Myopia / Hyperopia / Astigmatism   OD OS OU
Other:
Planned Procedure: LASIK / Enhancement / PRK / PTK   OD OS OU
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:
Nursing Care Plan / Risk to Fall / Pain Assessment Met   
  #@     #@
To Laser Room
Procedure Start
Procedure End
Procedure: LASIK / Enhancement / PRK / PTK   OD OS OU
Anesthesia: Alcaine 0.5% gtt in oper. Eye(s)
Prep: 1% Betadine
Other:
GTTS 1 per eye:
Surgeon:
Laser Techs:  
Assist:
Other:  
Comments:
POST OP
BP P R
Nursing Care Plan/Risk to Fall/Pain Assessment Met
Discharged with instructions
Discharge Time:  
Other
Accompanied by: Nurse Notes:
POST-OPERATIVE SUMMARY/DISCHARGE ORDER:
Diagnosis: Myopia / Hyperopia / Astigmatism   OD     OS     OU
Procedure Performed:
LASIK / Enhancement / PRK / PTK   OD OS OU
Custom Vue:           
Complications:     Other:  


Patient stable on discharge
Other:


RN Signature
Date
Physician Signature
Date
Time

LASIK FLOW SHEET     REV 07/18
PATIENT LABEL