Surgery Sheet Orders Details

Are you in charge of surgery scheduling for your hospital or clinic? If so, you know that it can be a daunting task. There are many factors to take into account when scheduling surgeries, from determining the best time for each procedure to coordinating with surgeons and other staff members. One tool that can make the process a little bit easier is a surgery scheduling sheet form. This form allows you to track all of the necessary information about each surgery, including the date, time, and surgeon involved. Having this information organized in one place makes it easy to see what surgeries are scheduled for each day and helps prevent overlap or delays.

Before you fill in surgery scheduling sheet, you should learn more concerning the type of form you are going to work with.

QuestionAnswer
Form NameSurgery Scheduling Sheet
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesphysician's surgical order sheet blood thinners, surgery scheduling sheet, surgery sheet admission, minor surgy scheduling forms

Form Preview Example

SURGERY SCHEDULING SHEET &

PHYSICIANS PRE-ADMISSION TESTING ORDERS

PLEASE FAX TO 866-647-0527, ALONG WITH COPY OF INSURANCE CARD

NAME

 

 

SURGERY DATE

ARRIVAL TIME

SURGERY TIME

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

PROCEDURE & CPT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**CIRCLE ONE**

R

L

 

 

 

 

 

 

 

PHONE (H)

 

 

DIAGNOSIS & ICD9

 

 

 

 

 

 

 

 

 

 

PHONE (W)

 

(C)

 

 

 

 

 

 

 

 

 

 

 

SS#

 

 

SURGEON

 

 

 

 

 

 

 

 

 

 

DOB

 

 

REFERRING PHYSICIAN

 

 

 

 

 

 

 

 

 

 

ALLERGIES

 

 

PCP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANESTHESIA TYPE

 

 

 

 

 

 

 

 

 

 

 

 

 

**CIRCLE ONE**

OP

 

23HR OBSERVATION

INPATIENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TEST

DONE

WHERE

Anesthesia

 

 

EKG

 

 

CBC

 

 

HEMOCUE

 

 

BASIC METABOLIC

 

 

PANEL

 

 

(BUN, CR, NA, K, CL,

 

 

CO2, Glucose)

 

 

COMPREHENSIVE METABOLIC PANEL (Albumin, Phosphate, AST, Bilirubin – Total, BUN, CA, CR, NA, K, CL, CO2, Glucose, Protein Total)

LIVER PANEL

BUN / Creatinine

TEST

DONE

WHERE

 

 

 

ELECTROLYTE

PANEL

K

BLOOD

PT / PTT

CHEST X-RAY

UR PREG / HCG

CRUTCH

TRAINING

ADDITIONAL ORDERS / SPECIAL INSTRUCTIONS:

_________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________

_________________________________________________________________

_________________________________________________________________________

**PHYSICIAN’S SIGNATURE**

DATE

PATIENT NAME:______________________________________________

SURGERY PROCEDURE:________________________________________

SURGEON:__________________________________________________

DATE OF SURGERY:___________________________________________

TIME OF SURGERY:_____________ ARRIVAL TIME:_________________

PATIENT INFORMATION:

Our professional staff is dedicated to providing the highest quality of individualized care to each of our patients. This patient focused approach is intended to promote long term health and well being that results in a high degree of patient satisfaction.

We want to make your upcoming visit as pleasant and comfortable as possible. To make your surgery a successful experience, please read and follow the information on the enclosed sheet.

DAY OF SURGERY:

OArrive promptly at the scheduled time. This will allow adequate time for all necessary pre-surgery procedures.

OPlease bring your insurance identification cards. If special financial arrangements are necessary, please call the Medical Center prior to arrival.

OBe sure to bring any paperwork your doctor gave you, such as test results and/or films, and a list of all medications you are taking.

OWear comfortable, loose fitting clothing.

OUpon arrival, you will change into a gown and slippers which we will provide. You will be asked to remove contact lenses, dentures and any prosthesis.

PREPARING FOR YOUR SURGERY:

Sometime before your surgery date, a staff member from the Medical Center will call you to confirm your surgery time.

They will also ask you questions regarding current and past medical conditions, allergies and medications you are taking. Please don’t hesitate to ask any questions you may have. Be sure to let the staff know of any special needs.

OYou will be instructed as to what time you are to stop eating and drinking prior to your surgery and what medications you should or should not take.

OFor women, if there is any possibility you are pregnant, please notify your doctor and the Medical Center nurse.

OLeave all valuables at home, including watches, rings, jewelry and wallets.

ONotify your surgeon of any changes in your health such as a cold or fever.

OFor your safety, please arrange for an adult to drive you home after surgery. You will not be allowed to drive yourself home.

MEDICAL CENTER at ELIZABETH PLACE

1 Elizabeth Pl, Dayton, OH 45408-1445

Telephone: 937-223-MCEP

DIRECTIONS and MAP

From South of Dayton

Take I-75 NORTH into Dayton

Take the Edwin C. Moses exit (#51)

Turn RIGHT at the end of the exit ramp onto Edwin C. Moses

Follow Edwin C. Moses just over 1 mile

Turn left onto Albany St (before the Dayton Heart Hospital)

Turn right onto Elizabeth Place

From North of Dayton

Take I-75 SOUTH into Dayton

Stay on I-75 (approximately 14 miles south of I-70)

Take the Albany Street exit

Turn LEFT at the end of the exit ramp onto Albany Street

Turn LEFT onto Cincinnati Street (at a 4-way stop)

Turn RIGHT onto Elizabeth Place

Valet Parking available in front of the West Pavilion (no charge). Enter through main entrance; turn right to go to the elevators. Take the elevator to the second floor; the medical center is to the left.