Download Pre-Op Order Template TSMH Pre

PATIENT NAME: DATE OF BIRTH:
SURGICAL PROCEDURE:
INPATIENT
OUTPATIENT
DATE:
HISTORY:
CURRENT CONDITION:
ALLERGIES:
CO-MORBIDITIES:
PREP:
Insert Foley Cath - Fleet Enema
Shower or Cleanse Prep - Vinegar Douche
Shaving Instructions -
OTHER:
DIETARY RESTRICTIONS:
NPO After Midnight
OTHER:
PRE OP MEDICATIONS / INSTRUCTIONS:
ANTIBIOTIC:
PO / IV / IM / SQ
OTHER:
PO / IV / IM / SQ
OTHER:
PO / IV / IM / SQ
DIAGNOSTIC PROCEDURES:
LAB: DX:
CBC
PLT Function Screen
APTT
WSR
HCG
CRP
BMP
CMP
INP
ACCU Check
UA (C&S If indicated)
BLOOD PRODUCTS:
Type and Screen
Type and Cross
CARDIO PULMONARY / IMAGING:
EKG DX:
OTHER:
#_____ Units PRBC
CXR DX:
DX:
Auto Blood Available? #_____ Units
Other
DX:
DX:
DX:
O2 - Incentive SpirometrySCD’s
TED HOSE: Knee Thigh
Left
Right
PHYSICIAN / PRACTITIONER’S SIGNATURE
DATE
TIME
TRI-STATE MEMORIAL HOSPITAL
CLARKSTON, WA
PRE OP ORDER SET