Risk Management

Surgery Face Sheet


CASE #:                                                                                                                INS. CO:                                                                               

AUTH #:                                                                               PATIENT NAME:                                                                              

SURGERY DATE:                                                             SURGERY TIME:                               AM        PM

PLACE OF SERVICE/HOSPITAL:                                                                                                                

TYPE OF SURGERY:                                                                         OD         OS           PATIENT AGE:                  


ANESTHESIA:                    L.S.B.     GENERAL            DIABETIC           YES        NO

COUMADIN:       YES        NO

ANESTHSIA GROUP:                                                                                      

PRIMARY CARE PHYSICIAN:                                                                                                                                     

PRE-OPT APPT. DATE:                                                                                     TIME:                                                   

POST-OP APPT. DATE:                                                                                     TIME:                                                   

KERATOTOMY          QUALITY OF KERATOTOMY:              GOOD                    AVG                       POOR


OD                                  X                             @            OD


                                                                                X                             @            AVG:                      X                            


                                                                                                X                             @           

                                                        OS                                   X                             @            OS

TECHNICIAN                                                     X                             @            AVG:                     X                            


                                                                                                X                             @           


INFORMED CONSENT GIVEN:     YES        NO          PRE-OP INSTRUCT GIVEN:           YES        NO


ACTIVITY SHEET GIVEN:             YES        NO          POST-OP INSTRUCT GIVEN:         YES        NO


INFORMED CONSENT DISCUSSED (INCL SPECIAL RISKS):                                                                                            









                OD:                                                         QUALITY OF SCAN:         GOOD                    AVG                       POOR


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