Risk Management



Surgery Face Sheet

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):                                                                                            

 

                                                                                                                                                                                                               

 

                                                                                                                                                                                                               

 

                                                                                                                                                                                                               

 

A-SCAN (SCANS STAPLED ON BACK)

                OD:                                                         QUALITY OF SCAN:         GOOD                    AVG                       POOR

                OS:                        

Please refer to OMIC's Copyright and Disclaimer regarding the contents on this website

Leave a comment



Six reasons OMIC is the best choice for ophthalmologists in America.

#1. Consistent return of premium.

Publicly-traded insurance companies exist to make profits for shareholders while physician-owned carriers often return profits to their policyholders. Don’t underestimate this benefit; it can add up to tens of thousands of dollars over the course of your career. OMIC has one of the most generous dividend programs for ophthalmologists and has returned more than $20 Million to our members through dividends.

61864684