PLACE LABEL HERE

GENERIC MEDICAL

ORDERS

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

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

Attending Physician:______

1. Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time spent in outpatient- ED, surgery, OBS)and the patient has medical necessity for an inpatient admission?

Yes, admit as inpatient, proceed to # 2No, place in observation

2. If admitted as inpatient, Inpatient Physician Certification:

Diagnosis: ______

Level of Care: Critical  Intermediate  Acute Care Location/Specialty Unit Preference______

  1. Telemetry: If patient Medical/Surgical, must complete Telemetry Orders (form # 36084)
  2. Isolation: Contact Droplet Airborne For: ______

5.Consults: ______

______

6.Diagnostics:

 CBC PT/PTT TSH CMP  Urinalysis

 Troponin

 CXR PA/lateral on admission

 EKG on admission (______to read)

 Serum hCG, for females 10-60 years of age, if no pregnancy test done in the ED

 Other: ______

Monitoring following hyperkalemia treatment in the ED

Potassium level q 2 hrs until hemodialysis initiated. Notify nephrologist if K ≥ 6.0

Glucose finger stick q 15 min x 2 then q 30 minutes x 3if IV insulin given in ED (not required if the glucose checks were completed in the ED)

Order BMP 2 hrs after hemodialysis treatment completed. Call results to hospitalist.

7.Initiate Sleep Apnea Standing Orders (form # 21266) IF OSA screen is positive for suspected or reported sleep apnea

8. Intake and output q shift

9. Foley catheter.

  1. Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)
  2. Weigh on admission
  3.  Weigh daily
  4. Vital signs per unit routine or q ____ hrs Glucose fingerstick ac & hs or q ____ hrs

14. O2for Adults Protocol (form # 34431)

15.Diet:  Regular  Cardiac  Diabetic______calories  Renal  Other: ______

16.Nutrition Supplement Standing Orders (form # 31417), initiate if patient meets criteria

17.Activity (advance as tolerated): Bed Rest  Bedside commode  Bathroom privileges

 Up ad lib  Up with assistance

18.Initiate PT/OT Protocol (form #32655) IF patient has a substantial decrease from base line function
(that is unlikely to resolve within 48 hrs), or needs placement and disposition.

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

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

SCHEDULED MEDICATIONS:

19. INTIVF:  NS LR  D5NS D5 ½ NS with 20 KCl at ______ml/hr

20. VTE prophylaxis, Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058)

Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg or age > 75)

or Lovenox (enoxaparin) 40 mg SQ daily at 1700 (30 mg if CrCl < 30 ml/min)

orContraindication to chemical prophylaxis: ______

and placemechanical devices: SCD’s

PRN MEDICATIONS(See policy 520-06 for range orders and pain intensity guidelines)

  1. Electrolyte Replacement Protocol (form # 21340)
  2. Mild Pain, Temp>100.5F, HA:Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
  3. Moderate Pain:

Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered.

or If patient cannot take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs prn instead of Norco. DC if Percocet ordered.

orPercocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered.

and/or  Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if CrCl 31-50, > 65 y/o old or <50 kg) or 10 mg po q 6 hrs prn (max combined duration of IV and po ketorolac is 5 days). DC if CrCl < 30.

  1. Severe Pain (Begin when Epidural or PCA has been discontinued)

Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered.

or Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 3 hrs prn. If CrCl < 30, dose at 0.25 mg. Hold for excessive sedation. DC if Morphine ordered.

  1. Nausea/Vomiting: Zofran (ondansetron) 4 mg IV or po q 6 hrs prn

If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)

  1. Sleep:  Melatonin 5 mg po q HS prn

or Ambien (zolpidem)5 mg (female or males ≥ 65 y/o) or 5-10mg (male < 65 y/o) po at HS prn

  1. Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
  2. Stool Softener: Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
  3. Constipation: Milk of Magnesia (MOM) 30 ml po daily prn

If no BM after 48 hrs, Dulcolax (biscodyl) 10 mg per rectum daily prn

and/or Senokot-S (docusate/senna) 2 tablets po at bedtime nightly

30.Cough:Robitussin (guaifenesin) 15 ml po q 4 hrs prn

31.Sore Throat:Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn

ADDITIONAL ORDERS:

______

______

______

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DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-18574 REV. 01/2018 Page 2 of 2