Orthopedic Pre-Operative Orders

Patient Name:

Today's Date:

Risk & Benefits:

Pre-Op Orders
I have explained the operation/procedure, alternatives, benefits and risks to the patient and have answered the patient’s questions to the best of my knowledge. I feel the patient has been adequately informed and has given their consent.

Dr. Signature:

Admit to
NPO After Midnight Before Surgery
Operative Permit for:
Start IV or 1000 cc LR or 1000 cc NACL if diabetic:
Clipper prep in Pre-Op

Cefazolin (Ancef) weight based
(2 grams if patient is 40kg to 120kg, 3 grams if patient is greater than 120kg, and 30mg/kg if patient is less than 40kg) IV pre-operatively, unless the patient has reported a severe allergic reaction to penicillin with any of the following symptoms (angioedema, hypotension, wheezing, nor bronchospasm), then give Clindamycin 900mg IV. If patient has any allergy to Cephalosporins, give Clindamycin 900mg IV.
Ancef 2gms IV Pre-Op if less than or equal to 120kg, 3gms if greater than 120kg. If less than 40kg, then 30mg/kg.
(If allergic to Penicillin, or Cephalosporins, give Clindamycin 900 mg IV)
Pre-Op medications per Anesthesia:
Physical Therapy:
Beta HCG (if female age 10-50 years old or is over the age of 50 and still menstruating)
Beta HCG (if female age 12-50)
Anesthesia Type:
Consult anesthesia for nerve block;
indication - post operative pain control.

Name:

DOB:

DOS:

Worker's Comp:

Scheduling & Orders

Orthopedic Scheduling Form

Orthopedic Pre-Operative Orders

Injection Orders