Post Acute Transfer Orders

PLACE LABEL HERE

POST ACUTE TRANSFER

ORDERS

The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

DIAGNOSIS: ______

ALLERGIES: ______

Provider name: ______Phone: ______

Follow up with Dr. ______Phone: ______In ______days/weeks

1.  Hospital Code Status at Time of Discharge: q DNR q Full code q Other: ______

2.  Current Isolation Status: q None q Yes/Type: ______

3.  Vital signs: q Routine q Other: ______

4.  Diet: q Low sodium diet q Renal q ______Calorie Consistent Carbohydrate

q Fluid restriction: ______ml/day

q Other: ______

q Tube Feeding: ______q Aspiration Precautions: ______

5.  Weight bearing/activity: ______

6.  Therapies: q PT ______q OT ______q SLP ______

Hold therapies for pulse < ______or O2 Sat < ______%

7.  q O2 @ ______via ______q Titrate Oxygen to keep Saturation greater than ______

8.  q Pulse oximetry checks every ______Trach care: ______

9.  Wound care/dressing changes: ______

DIAGNOSTICS:

10.  Lab: q BMP every ______q PT/INR

q Other: ______

11.  X-ray : ______

12.  Blood Glucose Monitoring: ______

SCHEDULED MEDICATIONS: q See attached Discharge Medicine List reconciled by the Provider

PRN MEDICATIONS:

13. Mild pain/temp > 100.5°F q Tylenol (acetaminophen) 650 mg po or rectal suppository q 6 hrs prn

14. Stool softener/Constipation: ______

15. Other: ______

q CHF PATIENTS (In case of conflicts between forms, the following written medication orders are to be followed)
·  Weigh patient daily
·  CHF Education
·  Notify physician at contact number above for weight gain > 3 pounds in one day or > 5 pounds in one week, chest pain not responsive to nitroglycerin x 2 doses or increased shortness of breath
q Beta Blocker: ______
Hold for BP < ______Pulse < ______Contraindication: ______
q ACE inhibitor or ARB: ______
Hold for BP < ______Contraindication: ______
q Diuretic: ______
q Anticoagulant: ______
q Aldosterone Antagonist: ______
q Aspirin: ______

ADDITIONAL ORDERS: ______

______

Date Time Physician Signature PID Number ______

If patient is not transferred within 24 hours of above date and time, transfer orders will be updated below and provided with new date, time, and signature:

Updated Orders: q None q Additional orders: ______

______

Date Time Physician Signature PID Number

*1-17885* FORM 1-17885 REV. 03/2016 WHITE: Medical Record CANARY:Post Acute Facility Page 1 of 1