Hall of Fame/HallofFameCDROM.cdr/busi/formgen.lzh/EXCOPRPT.FRM

Text File | 1989-12-19 | 4KB | 1 lines

   OPERATIVE REPORT                                     Operative eye:  OD  OS                               EXCIMER LASER STUDY                                 ╔════════════════════════════════════╦═════════════════════════════════════╗   ║Date ___/___/___ Chart #_________   ║  Anesthesia:                  Y N   ║   ║      m   d   y                     ║          Facial nerve block   ■ ■   ║   ║                                    ║   Topical Proparacaine 0.5%   ■ ■   ║   ║Pt. __________________ _______ ___  ║  3cc Retrobulbous lidocaine   ■ ■   ║   ║         Last           First  M.I. ║  Fornicial inj 2% lidocaine   ■ ■   ║   ╠════════════════════════════════════╬═════════════════════════════════════╣   ║                                    │          Topical Y N  Sub-tenon Y N ║   ║Ablated area size:___.___mm         │        Decadron  ■ ■            ■ ■ ║   ║Was visual axis marked??    (Y / N) │      Gentamycin  ■ ■            ■ ■ ║   ║Was procedure interrupted?? (Y / N) │  Homatropine 5%  ■ ■                ║   ║Procedure complete??        (Y / N) │ Collagen Shield  ■ ■                ║   ║Was treatment well centered (Y / N) │      Compound X  ■ ■                ║   ║                                    │ Other _____________________________ ║   ╠════════════════════════════════════╧═════════════════════════════════════╣   ║Laser parameters:                                                  Unknown║   ║          1. Optical zone setting . . . . . :______ millimeters       ■   ║   ║          2. Epithelial depth . . . . . . . :______ microns           ■   ║   ║          3. Epithelial ablation rate . . . :______ microns/shot      ■   ║   ║          4. Number of steps. . . . . . . . :______                   ■   ║   ║          5. Stromal ablation rate. . . . . :______ microns/shot      ■   ║   ║          6. Initial radius of curvature. . :______ Radians           ■   ║   ║          7. Desired dioptric correction. . :______ Diopters          ■   ║   ║          8. Magnification correction . . . :______                   ■   ║   ║          9. Repetition rate. . . . . . . . :______ Hertz             ■   ║   ║         10. Magnification level. . . . . . :______                   ■   ║   ║         11. Fluence. . . . . . . . . . . . :______ Mj/cm2            ■   ║   ╠══════════════════════════════════════════════════════════════════════════╣   ║   Additional notes (Include any significant variation from protocol.)    ║   ║                                                                          ║   ║                                                                          ║   ║                                                                          ║   ║                                                                          ║   ║                                                                          ║   ║                                                                          ║   ║                                                                          ║   ║                                                                          ║   ║                                                                          ║   ║                                                                          ║   ║                                                                          ║   ║                                                                          ║   ║         Investigator's signature ______________________________          ║   ╚══════════════════════════════════════════════════════════════════════════╝