Physician's Order Sheet
Patient Name:
PRE-OPERATIVE ORDERS
1.
Diagnosis:            
Mild/Moderate Glaucoma-        
2.
Procedure:           
       
       
3.
Admit to Salem Laser and Surgery Center
4.
Check Medication Reconciliation sheet for allergies.
5.
Routine admitting vital signs
6.
Nurse Anesthetist to evaluate patient if MAC
7.
Start saline lock. May use 2%, 0.1 to 0.2 ml for local anesthesia for insertion of IV needle.
8.
Place H&P in chart.
9.
PRE-OP MEDICATIONS:
  1.     Xanax (alprazolam) PO on admission for LenSx cases; dosage by physician preference:
    1.    For Drs. East, Neahring: 0.25mg for ALL patients.
    2.    For all other surgeons: 0.25mg for patients OVER 60, 0.50mg for patients 60 or UNDER.
  2.     Proparacaine 0.5% ophthalmic solution, 1-3 drops in operative eye PRN.
  3.     Give 1 drop of Compounded DILATING ophthalmic solution [contents below] in operative eye;
        repeat in 10 minutes PRN:
        -Tropicamide 1%
        -Phenylephrine 2.5%
        -Cyclopentolate 1%
        -Ketorolac 0.4%
        -Proparacaine 0.1%
10.
Check blood glucose level preoperatively on all insulin dependent patients.
11.
If lists, and/or patient reports EVER using an alpha adrenergic medication, give Atropine Sulfate 1% ophthalmic solution, 1 drop in operative eye; repeat in 5 minutes.
12.
Other
INTRA-OPERATIVE ORDERS
1.
Routine per preference card
2.
Other
POST-OP APPOINTMENT:
Date:
Time:
Signature
MD
Date:
Time:


PHYSICIAN ORDER SHEET       Rev. 06/17
(PATIENT LABEL)