Read web_nur_008_Ambulatory_Surgery_ text version

PLEASE REVIEW THE FOLLOWING GUIDELINES WHICH WERE APPROVED BY THE MEDICAL BOARD BEFORE COMPLETING THE FORM

PRE SURGICAL TESTING REQUIREMENTS HISTORY AND PHYSICAL EKG

All Patients

Within 30 days of surgery

Any patient with Diabetes, Hypertension, Cardiac, Vascular, Pulmonary, Renal, or Hepatic Disease All Men > 45 years old All Women > 55 years old

Within 3 months of surgery Not required Within 30 days of surgery

CHEST X-RAY LABORATORY WORK

General Anesthesia MAC

Anterior Segment Surgery under MAC only

Healthy Patient Diabetes Hypertension Cardiac/Pulmonary Renal Liver disease

none BMP

none BMP

none none

CBC, BMP PT/PTT, LFT INR

CBC, BMP PT/PTT INR

none

Coumadin therapy

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. Cataract Surgery under MAC does not require an EKG if there are no coexisting diseases, regardless of age.

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

08/2011

adm.020bForm Fast 3/09

310 East 14th Street New York, NY 10003-4297

ADULT PRE-OPERATIVE MEDICAL EVALUATION

Tel: (212) 979-4306 Fax: (866) 333-0174

Patient Name Surgical Procedure

Web Form

*NUR PREOPMEDEV*

Reset this Form

Patient Name:

Surgery Date Anesthesia Type

Date of Birth:

STABLE? YES NO

Surgeon HISTORY? NO YES

CONDITION

INDICATE CONDITION NUMBER # AND COMMENT BELOW REGARDING MEDICAL CONDITION TYPE AND DURATION

If Myocardial Infarction, indicate type and year(s):

1 2 3

Coronary Artery Disease Hypertension Congestive Heart Failure Cardiac Arrhythmia VaIvular Heart Disease Pulmonary Disease Diabetes Mellitus Bleeding Diathesis Renal Disease

H I S T 0 R Y

4 5 6 7 8 9

10 Hepatic Disease 11 Other Medical Condition(s)

Surgical History

Medication Allergy / Sensitivity

Last Menses (It Applicable) Tobacco Use ETOH Use Drug Use

M E D I D C O A& S T E I S 0 N S ABNORMAL DESCRIBE ABNORMAL FINDINGS

NORMAL P B.P. H HEART Y PULSE S LUNGS I C OTHER PERTINENT FINDINGS: A L LABORATORY, EKG, and X-Ray Evaluations

D deemed necessary. Send reports and mounted interpreted EKG's with this form. Please comment here on abnormal results. A T A C L E A R A N C E

Do you wish to make any peri-operative management recommendations? No Y

See reverse side of this form for minimum requirements. Supply other pertinent results and information as

STATEMENT OF CLEARANCE:

Examiner's Name (Printed) Examiner's Address Examiner's Signature

''There are no medical contraindications for the proposed procedure.'' License # Telephone #

Date

Time

Date

Time

09 /12

nur.008 Form Fast MED - 1/98 904028

SURGEONS REVIEW - I have reviewed this H&P and I evaluated the patient and there are no changes.

Surgeons Signature Print Name Date Time

Information

web_nur_008_Ambulatory_Surgery_

2 pages

Find more like this

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

806806


You might also be interested in

BETA
Clinical Review Criteria: External Neuromuscular Electrical Stimulator for Foot Drop, Bioness muscle stimulator for paralyzed hands
palivizumab (Synagis)
Beck Depression Inventory (BDI): A Reliability and Validity Test in The Malaysian Urological Population