www.marshallortho.com

GOOD SHEPHERD MC / MARSHALL - MARSHALL, TEXAS

INTRA-OPERATIVE ORDERS

[fill in blanks - cross out ones you don't use- add as needed on blank lines]

Date:     Time : _____________________

1. NaCl 0.9% ___________ mL to sterile field

2. NaCl 0.9% 3000 mL x ___ to surgi-lavage irrigation

3.  Kantrex 1 gram added to each 3000 mL of surgi-lavage irrigation? : ___  yes  ___no

4. Bacitracin 50.000 units added to each 3000 mL of surgi-lavage irrigation? : ___  yes  ___no

5. Dura-prep to ______________________________________________

6. Chlora-prep to ___________________________________________

7. Sensorcaine 0.25% with epinephrine ____ mL injected locally to operative site by surgeon

    Lidocaine 1% ____ mL injected locally to operative site by surgeon

    Sensorcaine 0.5% plain ___  mL injected locally to operative site by surgeon

8. Triple antibiotic ointment and adaptic with sterile dressing

9. NaCl 0.9% 3000 mL x ___ to arthroscopy irrigation

10. Epinephrine 1:1000 1 mL added to each 3000 mL of arthroscopy irrigation? : ___  yes  ___no

11.____________________________________________________

12. ___________________________________________________

verbal order Dr. _ / _________________________RN

read back and verified

____________________________  

Doctor's signature                           Date and Time

  PATIENT NAME:

FAMILY PHONE :

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