Physician Surgical Order Sheet
Patient Name
Date of Birth
Medical Record #
Procedure Date
Surgeon
Procedure Location
Preoperative Diagnosis
Planned Procedure(s)
Special Equipment or Implants
Allergies
Preoperative Orders
Additional Instructions
Medications
Medication
Dosage
Route
Frequency
Start Date/Time
Preoperative Labs/Studies
Blood Products Needed
Physician Signature
Date/Time