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Pain Level
/
|
Functional Pain Level
/
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NPO Since
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Pre-Op Meds
|
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Allergies/Reactions
|
Family/Ride Home
|
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Patient has a responsible adult to care for him/her at home after discharge from our center
|
|
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Consents signed
|
Comments
|
|
Patient & Procedure Verified
|
Comments
|
|
Patient Wristband
|
Comments
|
|
Surgical site marked, Confirmed
|
Comments
|
|
Photographed
|
Comments
|
|
History and Physical (within 24 hrs)
|
Comments
|
|
Diagnostic Studies
|
|
|
CBC / CMP / TSH
|
Comments
|
|
HIV / HEP C
|
Comments
|
|
PT/PTT/INR
|
Comments
|
|
EKG/CXR
|
Comments
|
|
CARDIAC CLR
|
Comments
|
|
MED CLEARANCE
|
Comments
|
|
PSYCH / NUTRITION
|
Comments
|
|
PREGNANCY
|
Comments
|
|
Reference Range: Negative = 1 Stripe, Positive = 2 Stripes
|
|
|
Prosthesis
|
|
|
Contact lenses
|
Comments
|
|
Glasses
|
Comments
|
|
Dentures
|
Comments
|
|
Other
|
Comments
|
|
Jewelry
|
Comments
|
|
Underwear
|
Comments
|
|
Learning Needs
|
|
|
Language Barriers
|
Comments
|
|
Cultural/Religious Conflicts
|
Comments
|
|
Physical Needs
|
Comments
|
|
Suspected Abuse or Neglect
|
Comments
|
|
Post-Surgical Garments
|
Comments
|
|
IV Insertion
|
|
|
Gauge
|
Site (Location)
|
|
Fluids & Rate/hr
|
|
|
IV Site Assessment
|
|
|
# Attempts
|
Site Clear
|
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Other
|
|
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Signature of nurse completing this form
|
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