ICU Admission Order Set

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