PRE SURGICAL TESTING REQUIREMENTS HISTORY AND PHYSICAL
PLEASE REVIEW THE FOLLOWING GUIDELINES WHICH WERE APPROVED BY THE MEDICAL BOARD BEFORE COMPLETING THE FORM
PRE SURGICAL TESTING REQUIREMENTS
HISTORY AND PHYSICAL
Within 30 days of surgery
All Patients
EKG
Any patient with Diabetes, Hypertension, Cardiac,
Vascular, Pulmonary, Renal, or Hepatic Disease
All patients >50 years old
Within 6 months of surgery
CHEST X-RAY
Not required
LABORATORY WORK
Within 30 days of surgery
General Anesthesia
Healthy Patient
Diabetes
Hypertension
Cardiac/Pulmonary
Renal
Liver disease
Coumadin therapy
none
BMP
CBC, BMP
PT/PTT, LFT
INR
MAC
Anterior Chamber Surgery- MAC only
none
none
BMP
none
CBC, BMP
PT/PTT
none
INR
none
For history of anemia or for surgeries where blood loss is expected to be >200cc, please include CBC
For patients on kidney dialysis, K+ should be obtained day of surgery
All diabetic patients glucose levels (i.e. finger stick) to be checked day of surgery
Urine pregnancy day of admission for all women of menstruating age
For patients with AICDs, please see NYEE's policy concerning defibrillators
Patients with more complex medical conditions may require further workup (i.e stress
tests, echocardiogram, cardio/pulmonary consult, etc). Please consult anesthesia
department or patient's PMD.
CBC = complete blood count, BMP = basic metabolic profile, LFT = Iiver ftinction test, K+ = potassium
PT/PTT/INR = prothrombin time/partial prothrombin time/international normalized ratio
AlCD = internal cardiac defibrillator
06/2014
adm.020bForm Fast 3/09
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Web Form
*ADM NOTSPORDER1*
PATIENT:
Second Avenue at 14th Street
New York, NY 10003
D.O.B:
ADMITTING NOTE & PRE-SURGICAL ORDERS
DATE OF ADMISSION:
PHYSICIAN:
ADMITTING DIAGNOSIS:
ADMITTING NOTE: (Admitting note contains sufficient information that include patient age, sex, initial assessment, reason for surgery or
admission any significant history or consultative findings, any special measures or precautions planned for the patient during care or treatment and
the anticipated complications, if any)
Intraocular Lens Verification:
TESTS DONE & RESULTS:
Manufacturer:
OTOLARYNGOLOGY
OPHTHALMOLOGY
Visual Acuity
Model:
OD
Tension
Power (diopters):
OD
OS
Audiogram
OS
Chest X-Ray
CT Scan
Fields
Slit Lamp
MRI
Fundoscopy
Other
Lens Selection Pending
Pediatric Cataract
ALLERGIES:
ADMISSION and PRE-SURGICAL ORDERS:
MEDICAL CONSULT/CLEARANCE:
AMBULATORY
INPATIENT
Med/Ped Consult Dr.
Outside Physician
PROCEDURE (TREATMENT):
ANESTHESIA:
DIET:
General
MAC
Standard NPO Orders
ADULT STANDARD DILATION:
Local
Other
OD
OS
PEDIATRIC STANDARD DILATION ORDER SET:
OD
OS
X1
X2
X3
Additional Orders: refer to Physician's Order Sheet
LABS (Note to all physicians, if lab work was done at an outside facility, results must be received by NYEEI 48 hrs. prior to admission)
No New Lab Orders - Tests not performed at NYEEI
Healthy Patient Protocol
Standard Lab Orders for Patient Who Has other Medical Conditions (please indicate the appropriate test panel order below)
DIABETES MELLITUS
HYPERTENSION
CARDIOVASCULAR/PULMONARY
HEPATIC
EXPECTED BLOOD LOSS>200cc
RENAL
(See reverse side for guidelines regarding pre-operative orders and labs testing panels)
Physician's Name (print)
Updated form - IOL Data Submission
adm.020 Form Fast 1/15
Physician's Signature
Submitter's Name (print)
Date
Date
Time
Time
................
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