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ALL ORDERS MUST BE WRITTEN WITH A BALL POINT PEN AND INCLUDE DATE, TIME, AND PHYSICIAN’S SIGNATURE.<br />
PHYSICIAN’S ORDER<br />
(EXCLUDING IV Fluids and MEDICATIONS)<br />
<strong>ICU</strong> <strong>Admission</strong> <strong>Order</strong> <strong>Set</strong> – Page 4 of 5<br />
DATE TIME INTRAVENOUS FLUID and MEDICATION<br />
ORDERS<br />
ALLERGY:<br />
STAT Labs and Diagnostics continued:<br />
□ CPK, MB, Troponin □ Chem 20<br />
□ Culture<br />
□ Urine<br />
□ Sputum<br />
□ Stool<br />
□ Blood x ____<br />
□ Other: ___________________________________<br />
□ CT Scan of: ______________________________<br />
□ With Contrast: □ IV □ Oral □ NGT<br />
□ OGT □ PEG □ Rectal<br />
□ WithOUT Contrast<br />
□ Portable CXR<br />
□ Ultrasound of _____________________________<br />
________________________________________<br />
□ Echocardiogram ___________________________<br />
to interpret study.<br />
□ EKG<br />
AM Labs and Diagnostics:<br />
□ CBC (auto diff) □ Liver Panel<br />
□ CBC (manual diff) □ UA<br />
□ PT/PTT<br />
□ D-Dimer<br />
□ Lactate<br />
□ ABG<br />
□ BNP □ CHEM 7<br />
□ Magnesium<br />
□ Phosphorus<br />
□ Ammonia<br />
□ Calcium<br />
□ LDH<br />
□ CPK, MB, Troponin<br />
□ Accucheck Every _____<br />
□ Culture □ Urine □ Sputum □ Urine<br />
□ Stool □ Other: ________________<br />
□ CT Scan of: ______________________________<br />
□ With Contrast: □ IV □ Oral<br />
□ WithOUT Contrast<br />
Continued on next page >>>>>><br />
IVF and MEDICATION ORDERS ONLY IVF and MEDICATION ORDERS ONLY IVF and MEDICATION ORDERS ONLY IVF and MEDICATION ORDERS ONLY<br />
□ MAGNESIUM REPLACEMENT PROTOCOL<br />
(NOT for use with Renal Patients)<br />
Check Magnesium Level.<br />
□ If magnesium level 1.6 – 1.7 mg/dL:<br />
Infuse 2 gram Magnesium Sulfate in 250 mL<br />
NSS IV over 8 hours.<br />
Repeat serum Magnesium Level 8 hours after<br />
completion of infusion.<br />
□ If magnesium level 1.4 – 1.5 mg/dL:<br />
Infuse 4 grams Magnesium Sulfate in 250 mL<br />
NSS IV over 8 hours.<br />
Repeat serum Magnesium Level 8 hours after<br />
completion of infusion.<br />
□ If magnesium level 1.2 – 1.3 mg/dL:<br />
Infuse 6 grams Magnesium Sulfate in 250 mL<br />
NSS IV over 8 hours.<br />
Repeat serum Magnesium Level 8 hours after<br />
completion.<br />
□ If magnesium level LESS THAN 1.2 mg/dL<br />
WITH Seizures:<br />
Infuse 4 grams Magnesium Sulfate in 250 mL<br />
D5W at a maximum rate of 3 mL/min.<br />
Continued on next page >>>>>><br />
<br />
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<br />
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<br />
Summary/Blanket orders are unacceptable.<br />
Medication orders must be complete.<br />
PRN medication orders must include an indication.<br />
Write legibly.<br />
Rewrite orders upon transfer and/or post-operatively.<br />
Date, time, and sign verbal & telephone orders within 48 hours.<br />
Physician’s <strong>Order</strong> Form (Page 4 of 5)<br />
<strong>ICU</strong> <strong>Admission</strong> <strong>Order</strong> <strong>Set</strong><br />
GMHA #049063 Stock # 99049063<br />
APPROVED DATE: Medicine Dept. 10/2010, MEC 07/2011, HIMC 03/2012<br />
DO NOT USE:<br />
U<br />
MS<br />
IU MSO 4<br />
Q.D. MgSO 4<br />
Q.O.D. Trailing zero<br />
Lack of leading zero<br />
MD initials:<br />
PATIENT ID LABEL