+ DOCTOR’S ORDER SHEET

DRUG ALLERGIES:

DAY SURGERY PRE-OP ORDERS PATIENT IDENTIFICATION ROOM NO.

Clinical Pathway 11/2016

DATE

/

TIME

/ ORDERS FOR MEDICATION, DIET AND TREATMENTS
PRE-ADMIT
1. Consent obtained for (procedure):
2. Diagnosis:
3. Hemogram
4. Na, K+ (if taking diuretics)
5. PT/INR if taking Warfarin (Coumadin)
6. UPT on all pre-menopausal women (except missed AB and previous BTL or hysterectomy)
7. Fingerstick Blood Glucose ______(if not drawn at physician’s office)
8. Serum Glucose (if Accucheck greater than 140 mg/dL)
9. Additional tests as indicated by medical necessity/diagnosis:
Labs done at Dr. ______’s office
CBC / HIV / Fingerstick Blood Glucose
UA (C & S if indicated) / EKG / Serum Glucose (if Accucheck > 140)
RPR / CXR / Type and Screen
TSH / UPT
Basic Metabolic Panel / RIAP
Comprehensive Metabolic Panel
If labs are done at doctor’s office, omit pre-admit lab order above.
10. Notify physician of glucose greater than 180.
PRE-OP Patient Weight:______
1. Admit to Surgical Care Unit for (procedure):
Outpatient Inpatient
2. NPO 8 hours prior to surgery except for AM meds as indicated (with sip of water).
3. UPT on all pre-menopausal women (except missed AB and previous BTL or hysterectomy)
if not done within 7 days.
4. Rh Immune Globulin workup if patient Rh negative or unknown.
5. Pre-op medication per Anesthesia.
6. IV of RL at 100 ml/hr.
7. May start IV with local anesthetic 1% Lidocaine (Xylocaine) at site.
8. Activity ad lib until pre-op medication given, then bedrest with BRP with assistance.

9. Give Ketorolac (Toradol) 30 mg IV (if forESSURE procedure give 1

hour prior to procedure). Reduce Ketorolac (Toradol) dose to 15 mg IV
if renally impaired or weighs less than 110 pounds. (if for ESSURE procedure
give 1 hour prior to procedure)
10. For DVT prophylaxis, refer to DVT Prophylaxis Clinical Pathway Orders for Surgical Patients.
11. For antibiotic administration, refer to Preoperative Prophylactic Antibiotic Administration Orders
12. Accucheck (if not performed in physician’s office or PreSurgical Center) If Blood Glucose less
than 70mg/dl greater than 180mg/dl,or patient on insulin pump, initiate Anesthesiology
PeriOperative Glucose Management Orders and notify Surgeon.

11/2016 DAY SURGERY PRE-OP ORDERS –Clinical Pathway