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<table width="700" border="0" cellspacing="1" cellpadding="1">
  <tr>
    <td align="center" valign="top" class="txtheading">Deshmukh Eye Hospital  Inpatient Document<br />        
      <strong><u>Preop Evaluation /  Checklist / OT Notes/ Postop Details</u></strong></span></td>
  </tr>
  <tr>
    <td align="left" valign="top">&nbsp;</td>
  </tr>
  <tr>
    <td align="left" valign="top"><span class="allsubhead">Patient Details : </span></td>
  </tr>
  <tr>
    <td align="left" valign="top" ><table width="100%" border="1" cellspacing="0" cellpadding="0">
      <tr>
        <td align="left" valign="top"><table width="100%" border="0" cellspacing="0" cellpadding="3">
          <tr>
            <td width="15%" align="left" valign="top"><span class="style3">Patient's Name</span></td>
            <td width="2%" align="center" valign="top"><span class="style3">:</span></td>
            <td width="23%" align="left" valign="top"><span class="style3"><strong><?php echo e($data->PatientName); ?></strong></span></td>
            <td width="8%" align="left" valign="top"><span class="style3">Age/Gender</span></td>
            <td width="2%" align="center" valign="top"><span class="style3">:</span></td>
            <td width="15%" align="left" valign="top"><span class="style3"><strong><?php echo e($data->Age); ?>/
  <?php echo e($data->Gender); ?></strong></span></td>
            <td width="8%" align="left" valign="top"><span class="style3">MRD No</span></td>
            <td width="4%" align="center" valign="top"><span class="style3">:</span></td>
            <td width="15%" align="left" valign="top"><span class="style3"><strong><?php echo e($data->MrdNo); ?></strong></span></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="style3"><span class="style5">Address</span></td>
            <td align="center" valign="top" class="style3"><span class="style5">:</span></td>
            <td class="style3"><span class="style6"><?php echo e($data->Address); ?></span></td>
            <td class="style3"><span class="style6"></span></td>
            <td align="center" valign="top" class="style3"><span class="style6"></span></td>
            <td class="style3"><span class="style6"></span></td>
            <td align="left" valign="top" class="style3"><span class="style5">Contact</span></td>
            <td align="center" valign="top" class="style3"><span class="style5">:</span></td>
            <td align="left" valign="top" class="style3"><span class="style8"><?php echo e($data->Phone); ?></span></td>
          </tr>
          <tr>
            <td colspan="9" align="left" valign="top" class="style3"><table width="100%" border="0" cellspacing="1" cellpadding="1" >
              <tr>
                <td width="18%" align="left" valign="top">Date of Admission : </td>
                <td width="16%" align="left" valign="top"><strong><?php echo e(date('d/m/Y', strtotime(str_replace('-', '/',$data->AdmissionDate)))); ?></strong></td>
                <td width="15%" align="left" valign="top">Date of Surgery :</td>
                <td width="17%" align="left" valign="top"><strong><?php echo e(date('d/m/Y', strtotime(str_replace('-', '/',$data->SurgeryDate)))); ?></strong></td>
                <td width="18%" align="left" valign="top">Date of Discharge :</td>
                <td width="16%" align="left" valign="top"><strong><?php echo e(date('d/m/Y', strtotime(str_replace('-', '/',$data->SurgeryDate)))); ?></strong></td>
              </tr>
            </table></td>
            </tr>
          <tr>
            <td colspan="9" align="left" valign="top" class="style3"><table width="100%" border="0" cellspacing="0" cellpadding="0">
              <tr>
                <td width="40%" align="left" valign="top">Provisional Diagnosis at the time of Admission : </td>
                <td width="60%" align="left" valign="top">&nbsp;<?php echo e($data->Diagnosis); ?></td>
              </tr>
            </table></td>
            </tr>
          <tr>
            <td colspan="9" align="left" valign="top" class="style3">Final Diagnosis at the time of Discharge : <?php echo e($data->Diagnosis); ?></td>
            </tr>
        </table></td>
      </tr>
    </table></td>
  </tr>
  

  <tr>
    <td align="left" valign="top"><table width="100%" border="0" cellspacing="1" cellpadding="1">
      <tr>
        <td width="69%" align="left" valign="top" class="allsubhead"><u>Preoperativenotes  (Ophthalmologist) (Ward)</span></u><span class="style28">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </td>
        <td width="31%" align="left" valign="top"><span class="allsubhead"><strong>Surgeon</strong></span></td>
      </tr>
      <tr>
        <td align="left" valign="top"><table width="100%" border="0" cellspacing="1" cellpadding="1">
          <tr>
            <td width="16%" align="left" valign="top" class="alltxtfnt">Sac patent&nbsp;&nbsp; </td>
            <td width="5%" align="left" valign="top"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
            <td width="18%" align="left" valign="top" class="alltxtfnt">IOL Power</td>
            <td width="2%" align="left" valign="top"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
            <td width="12%" align="left" valign="top" class="alltxtfnt">Fundus</td>
            <td width="2%" align="left" valign="top"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
            <td width="35%" align="left" valign="top" class="alltxtfnt">Xylocaine testing negative</td>
            <td width="3%" align="left" valign="top"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
          </tr>
          <tr>
            <td colspan="8" align="left" valign="top" class="alltxtfnt">Ocular condition is as noted.  Patient can be taken up for surgery </td>
            </tr>
          
          <tr>
            <td colspan="8" align="left" valign="top" class="allsubhead"><u>Modified WHO Surgical Safety  Checklist</u><u> </u></td>
          </tr>
        </table></td>
        <td align="center" valign="top"><table width="200" height="100" border="1" cellpadding="0" cellspacing="0">
          <tr>
            <td align="left" valign="top"><table width="100%" border="0" cellspacing="0" cellpadding="0">
              <tr>
                <td height="64" align="left" valign="top" class="alltxtfnt">Name &amp;Sign: <strong><?php echo e($data->Surgeon_Name); ?></strong></td>
              </tr>
              <tr>
                <td height="28" align="left" valign="top" class="alltxtfnt">Time&amp; Date:</td>
              </tr>
            </table></td>
          </tr>
          
        </table></td>
      </tr>
    </table></td>
  </tr>
  
  <tr>
    <td align="left" valign="top"><table width="100%" border="0" cellspacing="0" cellpadding="0">
      <tr>
        <td width="33%" align="left" valign="top"><table width="100%" border="0" cellspacing="1" cellpadding="1">
          <tr>
            <td colspan="2" align="left" valign="top" class="allsubhead"><u>SIGN  IN</u></td>
          </tr>
          <tr>
            <td width="85%" align="left" valign="top" class="allmarathitxt">&#2352;&#2369;&#2327;&#2381;&#2339;&#2366;&#2330;&#2375; &#2344;&#2366;&#2357;  &#2360;&#2369;&#2344;&#2367;&#2358;&#2381;&#2330;&#2367;&#2340; &#2325;&#2375;&#2354;&#2375; </td>
            <td width="15%" align="center" valign="middle"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="allmarathitxt">&#2321;&#2346;&#2352;&#2375;&#2358;&#2344;&#2330;&#2368; &#2348;&#2366;&#2332;&#2370; /&#2337;&#2379;&#2355;&#2366; &#2360;&#2369;&#2344;&#2367;&#2358;&#2381;&#2330;&#2367;&#2340; </td>
            <td align="center" valign="middle"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="allmarathitxt">&#2327;&#2369;&#2306;&#2327;&#2368;:&#2351;&#2306;&#2340;&#2381;&#2352;, &#2324;&#2359;&#2343;&#2375; &#2360;&#2369;&#2352;&#2325;&#2381;&#2359;&#2366; &#2340;&#2346;&#2366;&#2360;&#2339;&#2368; </td>
            <td align="center" valign="middle"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="allmarathitxt">&#2320;&#2309;&#2352;&#2357;&#2375; / &#2352;&#2325;&#2381;&#2340;&#2360;&#2381;&#2340;&#2381;&#2352;&#2366;&#2357; / &#2319;&#2354;&#2375;&#2352;&#2381;&#2332;&#2368;</td>
            <td align="center" valign="middle"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="allmarathitxt">&#2333;&#2366;&#2351;&#2354;&#2379;&#2325;&#2375;&#2344; &#2319;&#2354;&#2352;&#2381;&#2332;&#2368; &#2344;&#2366;&#2361;&#2368; </td>
            <td align="center" valign="middle"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
          </tr>
        </table></td>
        <td width="33%" align="left" valign="top"><table width="100%" border="0" cellspacing="1" cellpadding="1">
          <tr>
            <td colspan="2" align="left" valign="top" class="allsubhead"><u>TIME OUT </u></td>
          </tr>
          <tr>
            <td width="85%" align="left" valign="top" class="allmarathitxt">&#2350;&#2375;&#2337;&#2367;&#2325;&#2354; &#2335;&#2368;&#2350;&#2330;&#2368; &#2323;&#2355;&#2326; </td>
            <td width="15%" align="center" valign="middle"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="allmarathitxt">&#2352;&#2369;&#2327;&#2381;&#2339;&#2366;&#2330;&#2375; &#2344;&#2366;&#2357;&#2360;&#2369;&#2344;&#2367;&#2358;&#2381;&#2330;&#2367;&#2340;  &#2325;&#2375;&#2354;&#2375;</td>
            <td align="center" valign="middle"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="allmarathitxt">&#2321;&#2346;&#2352;&#2375;&#2358;&#2344;&#2330;&#2368; &#2348;&#2366;&#2332;&#2370; /&#2337;&#2379;&#2355;&#2366; &#2360;&#2369;&#2344;&#2367;&#2358;&#2381;&#2330;&#2367;&#2340;</td>
            <td align="center" valign="middle"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="allmarathitxt">&#2354;&#2375;&#2344;&#2381;&#2360;  &#2325;&#2344;&#2381;&#2347;&#2352;&#2381;&#2350; &#2325;&#2375;&#2354;&#2375;</td>
            <td align="center" valign="middle"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="allmarathitxt">&#2309;&#2346;&#2375;&#2325;&#2381;&#2359;&#2367;&#2340; &#2343;&#2379;&#2325;&#2381;&#2351;&#2366;&#2330;&#2368; &#2313;&#2332;&#2355;&#2339;&#2368; &#2325;&#2375;&#2354;&#2368;  &#2366;&#2361;&#2368; </td>
            <td align="center" valign="middle"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
          </tr>
        </table></td>
        <td align="left" valign="top"><table width="100%" border="0" cellspacing="1" cellpadding="1">
          <tr>
            <td colspan="2" align="left" valign="top" class="allsubhead"><u>SIGN OUT </u></td>
          </tr>
          <tr>
            <td width="85%" align="left" valign="top" class="allmarathitxt">&#2321;&#2346;&#2352;&#2375;&#2358;&#2344;&#2330;&#2375;/ &#2346;&#2381;&#2352;&#2325;&#2381;&#2352;&#2367;&#2351;&#2375;&#2330;&#2375; &#2344;&#2366;&#2357; &#2354;&#2367;&#2361;&#2367;&#2354;&#2375; </td>
            <td width="15%" align="center" valign="middle"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="allmarathitxt">&#2360;&#2381;&#2335;&#2368;&#2325;&#2352;  &#2354;&#2366;&#2357;&#2354;&#2375; / &#2324;&#2359;&#2343;&#2375; / &#2360;&#2370;&#2330;&#2344;&#2366; &#2342;&#2367;&#2354;&#2381;&#2351;&#2366; </td>
            <td align="center" valign="middle"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
          </tr>
          <tr>
            <td align="left" valign="top">&nbsp;</td>
            <td align="center" valign="top">&nbsp;</td>
          </tr>
          <tr>
            <td align="left" valign="top">&nbsp;</td>
            <td align="center" valign="top">&nbsp;</td>
          </tr>
          <tr>
            <td align="left" valign="top">&nbsp;</td>
            <td align="center" valign="top">&nbsp;</td>
          </tr>
        </table></td>
      </tr>
    </table></td>
  </tr>
  <tr>
    <td align="left" valign="top"><table width="100%" border="0" cellspacing="0" cellpadding="0">
      <tr>
        <td width="34%" align="left" valign="top">&nbsp;</td>
        <td colspan="2" align="left" valign="top">&nbsp;</td>
        <td colspan="2" align="left" valign="top">&nbsp;</td>
      </tr>
      <tr>
        <td align="left" valign="top" class="allsubhead">Nurse</td>
        <td width="2%" align="left" valign="top" class="allsubhead">&nbsp;</td>
        <td width="30%" align="left" valign="top" class="allsubhead">Anaesthetist</td>
        <td width="5%" align="left" valign="top" class="allsubhead">&nbsp;</td>
        <td width="29%" align="left" valign="top" class="allsubhead">Surgeon</td>
      </tr>
      <tr>
        <td width="34%"><table width="77%" height="100" border="1" cellpadding="0" cellspacing="0">
          <tr>
            <td align="left" valign="top"><table width="200" height="100" border="0" cellpadding="00" cellspacing="0">
              <tr>
                <td height="50" align="left" valign="top" class="alltxtfnt">Name &amp; Sign: </td>
              </tr>
              <tr>
                <td height="30" align="left" valign="top" class="alltxtfnt">Time &amp; Date :</td>
              </tr>
              
            </table></td>
          </tr>
          
        </table></td>
        <td colspan="2" align="center" valign="top"><table width="84%" border="1" cellpadding="0" cellspacing="0">
          <tr>
            <td align="left" valign="top"><table width="200" height="100" border="0" cellpadding="00" cellspacing="0">
              <tr>
                <td height="50" align="left" valign="top" class="alltxtfnt">Name &amp; Sign: </td>
              </tr>
              <tr>
                <td height="30" align="left" valign="top" class="alltxtfnt">Time &amp; Date :</td>
              </tr>
            </table></td>
          </tr>
          
        </table></td>
        <td colspan="2" align="right" valign="top"><table width="200" height="103" border="1" cellpadding="0" cellspacing="0">
          <tr>
            <td height="101" align="left" valign="top"><table width="200" height="100" border="0" cellpadding="00" cellspacing="0">
              <tr>
                <td height="50" align="left" valign="top" class="alltxtfnt">Name &amp; Sign: <strong><?php echo e($data->Surgeon_Name); ?></strong></td>
              </tr>
              <tr>
                <td height="30" align="left" valign="top" class="alltxtfnt">Time &amp; Date :</td>
              </tr>
            </table></td>
          </tr>
          
        </table></td>
      </tr>
    </table></td>
  </tr>
  
  <tr>
    <td align="left" valign="top">&nbsp;</td>
  </tr>
  <tr>
    <td align="left" valign="top" class="allsubhead"><u>Operative  Notes (See Software for further details)</u></td>
  </tr>
  <tr>
    <td align="left" valign="top" class="allsubhead"><u>Add Stickers / Implant details here </u></td>
  </tr>
  <tr>
    <td height="140" align="left" valign="top">&nbsp;</td>
  </tr>
  <tr>
    <td align="left" valign="top"><table width="100%" border="0" cellspacing="0" cellpadding="0">
      <tr>
        <td width="75%" align="left" valign="top" class="allsubhead">&nbsp;</td>
        <td width="25%" rowspan="4" align="left" valign="top"><table width="100%" border="0" cellspacing="0" cellpadding="0">
          <tr>
            <td align="left" valign="top" class="allsubhead">Surgeon</td>
          </tr>
          <tr>
            <td align="right" valign="top"><table width="200" height="100" border="1" cellpadding="0" cellspacing="0">
              <tr>
                <td width="10%" align="left" valign="top"><table width="200" height="100" border="0" cellpadding="00" cellspacing="0">
                  <tr>
                    <td height="50" align="left" valign="top" class="alltxtfnt">Name &amp; Sign: <strong><?php echo e($data->Surgeon_Name); ?></strong></td>
                  </tr>
                  <tr>
                    <td height="30" align="left" valign="top" class="alltxtfnt">Time &amp; Date :</td>
                  </tr>
                </table></td>
              </tr>
            </table></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="allsubhead">Surgeon</td>
          </tr>
          <tr>
            <td align="left" valign="top"><table width="100%" border="1" cellpadding="0" cellspacing="0">
              <tr>
                <td align="left" valign="top"><table width="200" height="100" border="0" cellpadding="00" cellspacing="0">
                  <tr>
                    <td height="50" align="left" valign="top" class="alltxtfnt">Name &amp; Sign: <strong><?php echo e($data->Surgeon_Name); ?></strong></td>
                  </tr>
                  <tr>
                    <td height="30" align="left" valign="top" class="alltxtfnt">Time &amp; Date :</td>
                  </tr>
                </table></td>
              </tr>
            </table></td>
          </tr>
        </table></td>
      </tr>
      <tr>
        <td align="left" valign="top" class="alltxtfnt">&nbsp;</td>
        </tr>
      <tr>
        <td align="left" valign="top" class="alltxtfnt">&nbsp;</td>
        </tr>
      <tr>
        <td align="left" valign="top" class="alltxtfnt"><table width="100%" border="0" cellspacing="0" cellpadding="2">
          <tr>
            <td><u>Preoperative notes (Ophthalmologist)(ward)</u></td>
          </tr>
          <tr>
            <td>Patient  comfortable </td>
          </tr>
          <tr>
            <td>Postoperative dressing  done and instructions given</td>
          </tr>
          <tr>
            <td>Please  discharge the patient. Continue treatment &amp; review schedule as per  discharge summary </td>
          </tr>
        </table></td>
        </tr>
    </table></td>
  </tr>
</table>
<p style="page-break-after: always;">&nbsp;</p>
<table width="700" border="0" cellpadding="2" cellspacing="2">
  <tr>
    <td align="center" valign="top" class="txtheading">Deshmukh Eye Hospital Inpatient Document</td>
  </tr>
  <tr>
    <td align="center" valign="top" class="txtheading"><u>PAC / Anesthesia notes  / Postoperative Evaluation</u></td>
  </tr>
  
  <tr>
    <td align="left" valign="top" class="allsubhead"><u>Preanesthetic Evaluation (PAC):&nbsp; COMORBITY</u></td>
  </tr>
  
  <tr>
    <td align="left" valign="top"><table width="700" border="0" cellspacing="1" cellpadding="1" class="alltxtfnt">
      <tr>
        <td width="103" align="left" valign="top" >Diabetic/ &#2337;&#2366;&#2351;&#2348;&#2368;&#2335;&#2368;&#2360;</td>
        <td width="32" align="left" valign="top"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
        <td width="108" align="left" valign="top">Htn/ &#2348;&#2367;&#2346;&#2368;</td>
        <td width="32" align="left" valign="top"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
        <td width="156" align="left" valign="top">HEART DISEASE/&#2361;&#2371;&#2342;&#2351;&#2352;&#2379;&#2327; </td>
        <td width="32" align="left" valign="top"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
        <td width="172" align="left" valign="top">ASTHMA/&#2358;&#2381;&#2357;&#2366;&#2360;&#2366;&#2330;&#2366; &#2340;&#2381;&#2352;&#2366;&#2360;</td>
        <td width="40" align="left" valign="top"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
      </tr>
      <tr>
        <td align="left" valign="top">ALLERGY /&#2309;&#2354;&#2352;&#2381;&#2332;&nbsp;&nbsp;&nbsp; </td>
        <td align="left" valign="top"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
        <td align="left" valign="top">H/O &#2349;&#2352;&#2381;&#2340;&#2368; &#2333;&#2366;&#2354;&#2375; &#2361;&#2379;&#2340;&#2375;&nbsp;&nbsp; </td>
        <td align="left" valign="top"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
        <td align="left" valign="top">&#2311;&#2340;&#2352;/OTHER&nbsp;&nbsp; </td>
        <td align="left" valign="top"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
        <td align="left" valign="top">&nbsp;</td>
        <td align="left" valign="top">&nbsp;</td>
      </tr>
    </table></td>
  </tr>
  
  <tr>
    <td align="left" valign="top" class="alltxtfnt">Co-morbidity-DM/ HTN /  IHD/ Others</td>
  </tr>
  <tr>
    <td align="left" valign="top" class="alltxtfnt">Current Medications/ &#2330;&#2366;&#2354;&#2370; &#2324;&#2359;&#2343;&#2368; </td>
  </tr>
  
  <tr>
    <td align="left" valign="top"><table width="700" border="0" cellspacing="0" cellpadding="0" class="alltxtfnt">
      <tr>
        <td width="64" align="center" valign="top">P</td>
        <td width="71" align="center" valign="top">&nbsp;</td>
        <td width="71" align="center" valign="top">R</td>
        <td width="71" align="center" valign="top">&nbsp;</td>
        <td width="78" align="center" valign="top">BP</td>
        <td width="95" align="center" valign="top">&nbsp;</td>
        <td width="81" align="center" valign="top">SPO2</td>
        <td width="94" align="center" valign="top">&nbsp;</td>
        <td width="75" align="center" valign="top">&nbsp;</td>
      </tr>
    </table></td>
  </tr>
  <tr>
    <td align="left" valign="top"><table width="700" border="0" cellspacing="2" cellpadding="2">
      <tr>
        <td width="474" align="left" valign="top" class="alltxtfnt">Plan of Anesthesia </td>
        <td width="212" rowspan="2" align="left" valign="top"><table width="100%" border="0" align="left" cellpadding="2" cellspacing="2">
          <tr>
            <td align="left" valign="top" class="allsubhead"><strong>Anesthetist</strong></td>
            </tr>
          <tr>
            <td align="left" valign="top"><table width="200" height="100" border="1" cellpadding="0" cellspacing="0">
              <tr>
                <td><table width="100%" height="100" border="0" cellpadding="0" cellspacing="0" class="alltxtfnt">
                    <tr>
                      <td height="26" align="left" valign="top">Name &amp;Sign: <strong></strong></td>
                    </tr>
                    <tr>
                      <td height="21" align="left" valign="top">Time&amp; Date:</td>
                    </tr>
                </table></td>
              </tr>
            </table></td>
          </tr>
          <tr>
            <td align="left" valign="top"><strong class="allsubhead">Anesthetist</strong></td>
          </tr>
          <tr>
            <td align="left" valign="top"><table width="200" height="100" border="1" cellpadding="0" cellspacing="0" class="alltxtfnt">
              <tr>
                <td align="left" valign="top"><table width="200" height="100" border="0" cellpadding="00" cellspacing="0">
                  <tr>
                    <td height="50" align="left" valign="top" class="alltxtfnt">Name &amp; Sign:</td>
                  </tr>
                  <tr>
                    <td height="30" align="left" valign="top" class="alltxtfnt">Time &amp; Date :</td>
                  </tr>
                </table></td>
              </tr>
            </table></td>
          </tr>

        </table></td>
      </tr>
      <tr>
        <td align="left" valign="top" class="alltxtfnt">Fitness for surgery  under planned anesthesia: Yes / High Risk Consent.&nbsp;&nbsp;&nbsp;&nbsp; ASA Grade <br />
          <table width="100%" border="0" cellspacing="0" cellpadding="0">
            <tr>
              <td colspan="9" align="left" valign="top" class="allsubhead"><strong>Preoperative<u>Preanesthetic Evaluation (Anesthesia) (Ward</u>):</strong> <strong>Anesthetist</strong></td>
              </tr>
            <tr>
              <td width="64" align="center" valign="top">P</td>
              <td width="71" align="center" valign="top">&nbsp;</td>
              <td width="71" align="center" valign="top">R</td>
              <td width="71" align="center" valign="top">&nbsp;</td>
              <td width="78" align="center" valign="top">BP</td>
              <td width="95" align="center" valign="top">&nbsp;</td>
              <td width="81" align="center" valign="top">SPO2</td>
              <td width="94" align="center" valign="top">&nbsp;</td>
              <td width="75" align="center" valign="top">&nbsp;</td>
            </tr>
            <tr>
              <td colspan="9" align="left" valign="top">Medication</td>
              </tr>
            <tr>
              <td colspan="9" align="left" valign="top"><p>To take for surgery as advised </p></td>
              </tr>
          </table></td>
        </tr>
    </table></td>
  </tr>
  <tr>
    <td align="left" valign="top"><table width="100%" border="0" cellspacing="0" cellpadding="0">
      <tr>
        <td width="5%">&nbsp;</td>
        <td width="95%" class="allsubhead"><strong><u>Anesthesia Notes and Monitoring</u></strong></td>
      </tr>
      <tr>
        <td align="center" valign="middle"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
        <td align="left" valign="top" class="alltxtfnt">Topical Anesthesia with 0.5 % Proparacain drops instilled in Conjunctival Cul-de-sac 3 times over 5 minutes&nbsp; </td>
      </tr>
      <tr>
        <td align="center" valign="middle"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
        <td align="left" valign="top" class="alltxtfnt">3 cc of 2% Xylocaine  Injection given in peribulbar space with a 24G blunt Needle</td>
      </tr>
      <tr>
        <td align="center" valign="middle"><img src="<?php echo e(url('square.jpg')); ?>" /></td>
        <td align="left" valign="top" class="alltxtfnt">Others </td>
      </tr>
    </table></td>
  </tr>
  <tr>
    <td align="left" valign="top"><table width="100%" border="0" cellspacing="0" cellpadding="0">
      <tr>
        <td width="49%" align="left" valign="bottom"><table width="100%" border="1" cellspacing="0" cellpadding="3" class="alltxtfnt">
          <tr>
            <td width="18%">&nbsp;</td>
            <td width="15%" align="center" valign="top">Pulse</td>
            <td width="16%" align="center" valign="top">Resp</td>
            <td width="16%" align="center" valign="top">BP</td>
            <td width="35%" align="center" valign="top">SpO2</td>
          </tr>
          <tr>
            <td align="left" valign="top">Preoperative</td>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
          </tr>
          <tr>
            <td align="left" valign="top">Intraoperative</td>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
          </tr>
          <tr>
            <td align="left" valign="top">Postoperative</td>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
          </tr>
        </table></td>
        <td width="51%" align="center" valign="top"><table width="98%" border="0" cellspacing="0" cellpadding="4">
          <tr>
            <td>__________________________________________</td>
          </tr>
          <tr>
            <td>__________________________________________</td>
          </tr>
          <tr>
            <td>__________________________________________</td>
          </tr>
          <tr>
            <td>__________________________________________</td>
          </tr>
        </table></td>
      </tr>
    </table></td>
  </tr>
  <tr>
    <td align="left" valign="top"><table width="100%" border="0" cellspacing="0" cellpadding="0">
      <tr>
        <td width="61%" align="left" valign="top"><table width="100%" border="0" cellspacing="0" cellpadding="0">
          <tr>
            <td align="left" valign="top" class="allsubhead"><strong><u>Postoperative  Notes (Anesthetist)(Ward)</u></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="alltxtfnt">Patient Comfortable</td>
          </tr>
          <tr>
            <td><table width="100%" border="0" cellspacing="0" cellpadding="0" class="alltxtfnt">
              <tr>
                <td width="64" align="center" valign="top">P</td>
                <td width="71" align="center" valign="top">&nbsp;</td>
                <td width="71" align="center" valign="top">R</td>
                <td width="71" align="center" valign="top">&nbsp;</td>
                <td width="78" align="center" valign="top">BP</td>
                <td width="95" align="center" valign="top">&nbsp;</td>
                <td width="81" align="center" valign="top">SPO2</td>
                <td width="94" align="center" valign="top">&nbsp;</td>
                <td width="75" align="center" valign="top">&nbsp;</td>
              </tr>
              <tr>
                <td colspan="9" align="left" valign="top">Medication</td>
              </tr>
              <tr>
                <td colspan="9" align="left" valign="top">&nbsp;</td>
              </tr>
            </table></td>
          </tr>
          <tr>
            <td class="alltxtfnt">Patient is fit to be discharged</td>
          </tr>
          <tr>
            <td class="alltxtfnt">To Continue medicines as per discharge summary&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </td>
          </tr>

        </table></td>
        <td width="20%" align="left" valign="top"><table width="100%" border="0" cellspacing="0" cellpadding="0">
          <tr>
            <td align="left" valign="top"><strong class="allsubhead">Anesthetist</strong></td>
          </tr>
          <tr>
            <td align="left" valign="top"><table width="100%" border="1" cellpadding="0" cellspacing="0">
              <tr>
                <td align="left" valign="top"><table width="200" height="100" border="0" cellpadding="00" cellspacing="0">
                    <tr>
                      <td height="50" align="left" valign="top" class="alltxtfnt">Name &amp; Sign:</td>
                    </tr>
                    <tr>
                      <td height="30" align="left" valign="top" class="alltxtfnt">Time &amp; Date :</td>
                    </tr>
                </table></td>
              </tr>
            </table></td>
          </tr>
        </table></td>
      </tr>
    </table></td>
  </tr>
  <tr>
    <td align="left" valign="top" class="allsubhead"><strong><u>Additional Notes</u></strong></td>
  </tr>
  <tr>
    <td height="100" align="left" valign="top" class="alltxtfnt">&nbsp;</td>
  </tr>
  <tr>
    <td align="left" valign="top" class="allmarathitxt"><strong>&#2310;&#2350;&#2381;&#2361;&#2366;&#2354;&#2366;  &#2321;&#2346;&#2352;&#2375;&#2358;&#2344;&#2344;&#2306;&#2340;&#2352;&#2330;&#2368; &#2325;&#2366;&#2355;&#2332;&#2368; &#2360;&#2350;&#2332;&#2357;&#2354;&#2368; &#2310;&#2361;&#2375;,&#2321;&#2346;&#2352;&#2375;&#2358;&#2344;&#2344;&#2306;&#2340;&#2352;&#2330;&#2381;&#2351;&#2366; &#2360;&#2370;&#2330;&#2344;&#2366;&#2306;&#2330;&#2366; &#2357;&#2321;&#2346;&#2352;&#2375;&#2358;&#2344;&#2330;&#2381;&#2351;&#2366; &#2360;&#2306;&#2349;&#2366;&#2357;&#2381;&#2351; &#2343;&#2379;&#2325;&#2381;&#2351;&#2366;&#2306;&#2330;&#2366; &#2357;&#2381;&#2361;&#2367;&#2337;&#2367;&#2351;&#2379; &#2342;&#2366;&#2326;&#2357;&#2354;&#2366;. &#2337;&#2367;&#2360;&#2381;&#2330;&#2366;&#2352;&#2381;&#2332; &#2325;&#2366;&#2352;&#2381;&#2337;, &#2360;&#2352;&#2381;&#2357; &#2352;&#2367;&#2346;&#2379;&#2352;&#2381;&#2335; &#2350;&#2367;&#2355;&#2366;&#2354;&#2375;&#2340;</strong></td>
  </tr>
  <!--<tr>-->
  <!--  <td align="left" valign="top" class="allmarathitxt">&nbsp;</td>-->
  <!--</tr>-->
  <tr>
    <td align="left" valign="top"><table width="100%" border="1" cellspacing="0" cellpadding="0">
      <tr>
        <td align="left" valign="top"><table width="100%" border="0" cellspacing="0" cellpadding="11" class="allmarathitxt">
          <tr>
            <td width="47%" align="left" valign="top">&#2346;&#2375;&#2358;&#2306;&#2335;&#2330;&#2375;  &#2344;&#2366;&#2357;  <?php echo e($data->PatientName); ?></td>
            <td width="32%" align="left" valign="top">&#2346;&#2375;&#2358;&#2306;&#2335;&#2330;&#2368;  &#2360;&#2361;&#2368; _________________ </td>
            <td width="21%" align="left" valign="top">&#2340;&#2366;&#2352;&#2368;&#2326;_____________</td>
          </tr>
          <tr>
            <td align="left" valign="top">&#2344;&#2366;&#2340;&#2375;&#2357;&#2366;&#2312;&#2325;&#2366;&#2306;&#2330;&#2375;&#2344;&#2366;&#2357; <?php echo e($data->RelativeName1); ?></td>
            <td align="left" valign="top">&#2344;&#2366;&#2340;&#2375;&#2357;&#2366;&#2312;&#2325;&#2366;&#2306;&#2330;&#2368;  &#2360;&#2361;&#2368; __________ </td>
            <td align="left" valign="top">&#2344;&#2366;&#2340;&#2375;_____________</td>
          </tr>
          <tr>
            <td height="38" align="left" valign="top">&#2337;&#2367;&#2360;&#2381;&#2330;&#2366;&#2352;&#2381;&#2332;  &#2342;&#2375;&#2339;&#2366;&#2353;&#2381;&#2351;&#2366;&#2330;&#2375; &#2344;&#2366;&#2357; _______________________ </td>
            <td align="left" valign="top">&#2360;&#2361;&#2368;__________________</td>
            <td align="left" valign="top">&#2357;&#2375;&#2355;_____________</td>
          </tr>
        </table></td>
      </tr>
    </table></td>
  </tr>
</table> 
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