This form must be completed the evening prior to surgery or, at the latest, by 6:00 a.m. the morning of.

Y

N

N/A

 

 

 

 

Patient identified via bar code  

 

 

 

General Consent  

 

 

 

Operative Consent (Witnessed/Date/Time)

 

 

 

Blood Transfusion Consent  

 

 

 

History & Physical (Completed within 30 days of surgery)  

 

 

 

Allergy bracelet on  

 

 

 

For Latex Allergy Notify Operating Room Immediately   

 

 

 

Internal Defibrillator / Pacemaker  

 

 

 

Pacemaker Rep Notified  

 

 

 

DNR temporarily suspended.  

 

 

 

Blood Type/Screen/Crossmatch  

 

 

 

Number of units  

 

 

 

FFP  

 

 

 

Number of Units  

 

 

 

Platelets  

 

 

 

Number of units  

 

 

 

Blood bracelet on  

 

 

 

EKG  

 

 

 

Stress test  

 

 

 

Echo

 

 

 

 

 

 

 

 

Other:

Pt on levonox ? plavix?

Must stop

2 days

5 days

 

Notify physician

 

 

 

Radiology:

 

 

 

 

 

 

 

 

Chest X-ray

 

 

 

 

 

 

 

 

Special

 

 

 

 

 

 

 

 

Blood Glucose

Notify physician if value > 250

 

Date/Time

 

 

 

H&H

Notify physician if value < 10/30

 

Date/Time

 

 

 

Platelets

Notify physician if value <100,000

Date/Time

 

 

 

PTT

Notify physician if

<23.0 or >33.4

 

Date/Time

 

 

 

INR

Notify physician if

>1.5

 

 Date/Time =

 

 

 

K+

Notify physician if

<3.5 or

>5.3

 Date/Time __

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Last modified: May 06, 2007