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Family/Referring Doctor Name
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Diagnosis
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Procedure
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Surgeons Assisting
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Consent Form Obtained?
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Risk, Benefits, Alt. Explained
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Blood Type
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Type & Screen in last 72hr?
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PT, PTT, INR
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Urinalysis Findings
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Hgb & Hct
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Chem7 Profile
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EKG Findings
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CXR Findings
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Medical / Cardiology Clearance?
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NPO after 12am
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Heparin gtt
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IV Fluids TKO
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HEENT
• • •
|
HEENT
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HR
• • •
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HR
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LUNGS
• • •
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LUNGS
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GYN/PELVIC
• • •
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GYN/PELVIC
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ABDOMEN
• • •
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ABDOMEN
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EXTREMITIES
• • •
|
EXTREMITIES
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ETA OR Time
|
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Assessment
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Plan
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