Medical Forms--Anesthesiology

Gardner Anesthesia Service
PCM Data Data Collection by non-physician to Pre-Anesthesia Testing System
Anesthesia Record 1. Consent for anesthesia
2. Preoperative evaluation
3. Anesthesia record
4. Post-op standing orders
5. Use Hints
PCA Orders Patient Controlled Analgesia standing order form
PSA Policy & Procedure 1. Procedural Sedation and Analgesia Policy and Procedure
Neuraxial Analgesia 1.  Post-op neuraxial order form
2.  Neuraxial analgesia record, page 1
3.  Neuraxial analgesia record, page 2
PCM Communication 1. To PCP: Patient has PCM risk, please evaluate and manage
2. To PCP: Patient with PCM risk had uneventful surgery--please follow
3. To PCP: Urgent--pt showed adverse cardiac event--please manage
OB Epidural 1. OB Neuraxial Analgesia Consent form
2. Nursing order form for neuraxial analgesia in obstetrics and after delivery
3. OB Neuraxial Analgesia monitoring record
4. Page 2 of the monitoring record
5. Illustrative Examples
Epidural Catheter Test Logic: To confirm correct placement of the epidural catheter
Fast Track Policy Policy -- Fast Track -- choose venue for postoperative care
Consent for Surgery Consent for surgical procedure
Pain Consults 1. Transmit clinical information and request to pain service
2. Return a report of clinical pain management service
CRPS Severity 1. Instructions
2. Evaluation form
3. Graphic depiction of RSD symptoms
Controlled Substance Log 1. Controlled substance log--obstetric operating room
2. Controlled substance log--main operating room
Diet Sheet The Eat All You Can Eat Diet
Evaluate a Surgeon 1. Overview
2. Score sheet
3. Venn diagram

David C. Flemming, MD, Curriculum Vitæ

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