YAG Laser Flow Sheet / Orders

Advance / Directive: Yes No

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:

is likely to improve patients poor vision

Other:

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:

PAR conference done by physician

Drug Allergies:

RXN:

NAUSEA

VOMIT

RASH

SHOCK

OTHER

See Page 2 for additional medications and / or drug allergies

Signature

Date:

Time: :

REASSESSMENT: H & P Current and valid. No Changes

Other:

Signature

Date:

Time: :

PRE / INTRA-OP

Admit Time:

Alert & Oriented:

Other:

BP:

PO2:

Tropicamide 0.5%; Phenylephrine 1.25% - 1 gtt, 1-2 in operative eye

JCB Lab: Lot #

Exp.

Initial

Time

Anesthesia: None Alcaine 0.5% 1 gtt in oper. eye

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: Ambulatory
Other
Accompanied by: Nurse Notes:

Medications: 1 gtt in: OD OS
Alphagan 0.2%
Betoptic S 0.25%
Other:

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

Complications: None Other:

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

RN Signature

Date

Physician Signature

Date

Time

PATIENT LABEL