SALEM LASER AND SURGERY CENTER
Physician's Order Sheet
YAG LASER: CAPSULOTOMY OR IRIDOTOMY
Patient Name:
PRE-OPERATIVE ORDERS
Procedure:
1. Admit to Salem Laser and Surgery Center
2. Routine admitting vital signs
3. H & P on chart; verify allergies
4. Capsulotomy Medication Orders:


5. Iridotomy Medication Orders:


6. Anesthesia: Proparacaine 0.5% 1-3 gtts in operative eye
7. Other:  
POST-OPTERATIVE ORDERS
1. Routine post-operative vital signs
2. Post-Operative Medication Orders:


3. Other:  
Signature:
MD
Date:
Time:
PHYSICIAN ORDER SHEET - YAG       0519
(PATIENT LABEL)

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

YAG Laser Flow Sheet / Orders
Advance / Directive:
Patient Name:
Procedure Date:
PRE-OPERATIVE HISTORY
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:
Findings: Opacified posterior lens capsule OD OS
VA:
BAT:
Other:
Pre-op Diagnosis:Opacified posterior lens capsule OD OS
Other:
Planned Procedure:YAG laser posterior capsulotony, OD OS
Other:
Significan Medical History:
Previous Cataract Surgery with IOL, OD OS
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:
Other:
BP:
P:
R:
T:
PO2:
Tropicamide 0.5%; Phenylephrine 1.25% - 1 gtt, 1-2 in operative eye
JCB Lab: Lot #
Exp.
Initial
Time
Anesthesia:      
Initial
Time
Surgical Safety Checklist Time out with verification of procedure/site complete
Initial
Time
Procedure: YAG laser posterior capsulotomy OD OS Millijoules Pulses
Nurse Notes:
RN Signature:
Date:
POST OP
BP P R PO2
Discharged with instructions
Discharge Time:  
Other
Accompanied by: Nurse Notes:
Medications: 1 gtt in:     OD   OS




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

Complications:     Other:  

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

RN Signature
Date
Physician Signature
Date
Time

PATIENT LABEL

Salem Laser & Surgery Center, LLC
Patient Last, First Name
Surgery Date
Eye
Pterygium without Graft
Pterygium with Amniotic Graft
Pterygium with Conjunctival Auto Graft
Mitomycin
5FU
Tisseel Glue
Retrobulbar Block
Notes
Patient Label
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