Your Hospital’s Name
Patient Name:
DOB:
MRN:
Physician:
FIN:
Physician’s Orders
Gynecological/Urology Surgery
PRE-OPERATIVE
Date:
Time:
Attending Physician:
Allergies/Sensitivities:
Allergy Information
Diagnosis/Procedures
Height:
Weight:
See/Update Electronic Health Record
Primary:
Secondary:
Procedures:
ALL DESIRED ORDERS MUST BE CHECKED OR COMPLETED
Confidentiality of this medical record shall be maintained except when use or disclosure is required
or permitted by law, regulation, or written authorization by the patient.
PROCEDURES/TREATMENT
Pre-operative laboratory work, x-rays, and ECG as per Anesthesia Guidelines
Intravenous (IV) per Anesthesiologist Orders
Pre-operative medication according to Anesthesiologist Orders
Obtain consent form if not already completed
NUTRITION AND DIET
Nothing by mouth for 8 hours
MEDICATIONS
Starting with January 2012 outpatient encounters, the IM route for all recommended antibiotics
will be acceptable for transrectal prostate biopsies.
ANTIBIOTICS given orally can be given for Transrectal Prostate Biopsies only
Quinolones are the only group of oral antibiotics allowed (may be taken at home prior to arrival
for procedure).
 Ciprofloxacin
 Levofloxacin
 Ofloxacin
ANTIBIOTICS (elect one of the following antibiotics below).
Cefazolin
 For weight less than 80 kg, 1 gram IV piggyback within 60 minutes pre-operatively
 For weight 80 kg or greater, 2 grams IV piggyback within 60 minutes pre-operatively
If B-lactam allergy (Select one of the following antibiotic combination below.)
Gentamicin (Pharmacy to dose) IV piggyback within 60 minutes pre-operatively and Clindamycin
900 mg IV piggyback within 60 minutes pre-operatively
OR
Gentimacin (Pharmacy to dose) IV piggyback within 60 minutes pre-operatively and
Metronidazole 500 mg IV piggyback within 60 minutes pre-operatively
Pre-operative antibiotics must be started within 60 minutes of surgery incision time.
OTHER
Telephone order/Verbal order documented and read-back completed. Practitioner’s initials
NOTE: Unless Order is written DAW (dispense as written), medication may be supplied which is a
generic equivalent by nonproprietary name.
TRANSCRIBED:
Date
Time
VALIDATED:
Date
Time
Sign
R.N. Sign
ORDERED:
Date
Time
Physician Print
Pager#
Physician Sign
Developed by Spectrum Health
Revised and Updated April 2013 by FMQAI to represent the changes to the Specifications Manual 6.0b.