*111* attach patient label here

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1 Physician Orders ADULT [R] = will be ordered Height: cm Weight: kg Allergies: No known allergies Medication allergy(s): Latex allergy Other: Admission/Transfer/Discharge Patient Status Initial Inpatient Attending Physician: Bed Type: [X] Med Surg 10 East Critical Care Stepdown Obstetrics Other Bed Type: [X] Med Surg 10 Thomas Critical Care Stepdown Obstetrics Other Bed Type: Med Surg [X] Critical Care 7 East Stepdown Obstetrics Other Patient Status Initial Outpatient Attending Physician: Outpatient Status/Service: OP-Ambulatory OP-Diagnostic Procedure OP-Observation Services NOTE to MD: Initial status inpatient --- For a condition/dx with severity of illness or co-morbid conditions indicating a hospital stay greater than 24 hours is required. Initial Status Outpatient Ambulatory surgery Outpatient surgery/procedure with discharge anticipated after a routine or, in some cases, extended recovery. Routine recovery after outpatient surgery is estimated at 6-8 hours. Extended routine recovery may be required for a patient to stay longer (could be overnight) to recover from anticipated sequela of surgery including effects of anesthesia, nausea, pain. For unanticipated sequela of surgery or a complicated post operative course, the patient may require a status change to inpatient. Please consult with a case manager before making this choice of status change. Examples: Initial status outpatient is generally selected for patients undergoing PCI, diagnostic caths, EP studies, ablations, pacemaker implantations, other routine surgeries. Initial status Outpatient -Observation Services Short term treatment, assessment and reassessment - estimate discharge within 24 hours In some cases (for Medicare patients), this can be extended to 48 hours. Observation Services can also be utilized when it is unclear (without additional assessment) whether the patient will require an inpatient stay. Notify physician once T;N, of room number on arrival to unit Primary Diagnosis: Secondary Diagnosis: Vital Signs Vital Signs T;N, q8h, T,P,R, & BP Vital Signs T;N, q4h, T,P,R, & BP Note: If patient is diabetic place order below : Orthostatic Blood Pressure T; N, Routine, qam Activity Out of Bed T;N, Up as tolerated Bedrest w/brp T;N, Food/Nutrition NPO T;N, except for meds NPO Start at T;23:59, except for meds Renal Diet On Dialysis T;N, Age Group: Adult >18 years Renal Diet Not On Dialysis T;N, Age Group: Adult >18 years Regular Adult Diet T;N ADA Adult Diet 1800 Cal Plan ADA Adult Diet 2000 Cal Plan Page 1 of 8 *111*

2 [R] = will be ordered Patient Care VTE Medical Prophylaxis Plan See separate sheet Physician Orders ADULT Consent Signed For T;N, Procedure: kidney biopsy Daily Weights T; N, Routine, qam Intake & Output T; N, Routine, q8hrs Telemetry T;N, Routine NOTE: If patient is NPO place order below: Whole Blood Glucose Nsg T;N, q6h NOTE: If patient receiving diet place order below: Whole Blood Glucose Nsg T;N, achs IV Insert/ Site Care T;N, Routine Nursing Communication T;N, If Temperature greater than 38.3 degrees C place orders for Blood Culture x2, Urine Culture and Gram Stain for sputum Nursing Communication T;N, Assess dialysis access site and record Oxygen- Nasal Cannula Respiratory Care T;N, Routine, 2 L/min Continuous Infusions D5 1/2 NS 1000mL,IV,Routine,T:N, at 50 ml/hr Normal Saline 1000mL,IV,Routine,T:N, at 50 ml/hr 1/2 NS 1000mL,IV,Routine,T:N, at 50 ml/hr Medications Immunosuppression Medications NOTE: Verify that patient is receiving qday or bid dosing for. 0.5 mg, Cap, PO, qam, Routine, T;N, To be given at 0600 Draw level prior to Comments: For organ 1 mg, Cap, PO, qam, Routine, T;N, To be given at 0600 Draw level prior to Comments: For organ 2 mg, Cap, PO, qam, Routine, T;N, To be given at 0600 Draw level prior to Comments: For organ 3 mg, Cap, PO, qam, Routine, T;N, To be given at 0600 Draw level prior to Comments: For organ 4 mg, Cap, PO, qam, Routine, T;N, To be given at 0600 Draw level prior to Comments: For organ 5 mg, Cap, PO, qam, Routine, T;N, To be given at 0600 Draw level prior to Comments: For organ 6 mg, Cap, PO, qam, Routine, T;N, To be given at 0600 Draw level prior to Comments: For organ 7 mg, Cap, PO, qam, Routine, T;N, To be given at 0600 Draw level prior to Comments: For organ 8 mg, Cap, PO, qam, Routine, T;N, To be given at 0600 Draw level prior to Comments: For organ 0.5 mg, Cap, PO, qpm, Routine, T;N, To be given at 1800, Comments: For organ 1 mg, Cap, PO, qpm, Routine, T;N, To be given at 1800, Comments: For organ Page 2 of 8

3 Physician Orders ADULT [R] = will be ordered Immunosuppression Medications continued 2 mg, Cap, PO, qpm, Routine, T;N, To be given at 1800, Comments: For organ 3 mg, Cap, PO, qpm, Routine, T;N, To be given at 1800, Comments: For organ 4 mg, Cap, PO, qpm, Routine, T;N, To be given at 1800, Comments: For organ 5 mg, Cap, PO, qpm, Routine, T;N, To be given at 1800, Comments: For organ 6 mg, Cap, PO, qpm, Routine, T;N, To be given at 1800, Comments: For organ 7 mg, Cap, PO, qpm, Routine, T;N, To be given at 1800, Comments: For organ 8 mg, Cap, PO, qpm, Routine, T;N, To be given at 1800, Comments: For organ 1 mg, Tab, PO, Qday, Routine, T;N, To be given at 0600, Draw level prior to 2 mg, Tab, PO, Qday, Routine, T;N, To be given at 0600, Draw level prior to 3 mg, Tab, PO, Qday, Routine, T;N, To be given at 0600, Draw level prior to 4 mg, Tab, PO, Qday, Routine, T;N, To be given at 0600, Draw level prior to 5 mg, Tab, PO, Qday, Routine, T;N, To be given at 0600, Draw level prior to 6 mg, Tab, PO, Qday, Routine, T;N, To be given at 0600, Draw level prior to 7 mg, Tab, PO, Qday, Routine, T;N, To be given at 0600, Draw level prior to 8 mg, Tab, PO, Qday, Routine, T;N, To be given at 0600, Draw level prior to NOTE : Neoral and Gengraf are NOT interchangeable with Sandimmune. 25 mg, Cap, PO, bid, Routine, T;N, To be given at 0600 and Draw level prior 50 mg, Cap, PO, bid, Routine, T;N, To be given at 0600 and Draw level prior 75 mg, Cap, PO, bid, Routine, T;N, To be given at 0600 and Draw level prior 100 mg, Cap, PO, bid, Routine, T;N, To be given at 0600 and Draw level prior 200 mg, Cap, PO, bid, Routine, T;N, To be given at 0600 and Draw level prior Page 3 of 8

4 Physician Orders ADULT [R] = will be ordered Immunosuppression Medications continued 25 mg, Cap, PO, bid, Routine, T;N, To be given at 0600 and Draw level prior 50 mg, Cap, PO, bid, Routine, T;N, To be given at 0600 and Draw level prior 75 mg, Cap, PO, bid, Routine, T;N, To be given at 0600 and Draw level prior 100 mg, Cap, PO, bid, Routine, T;N, To be given at 0600 and Draw level prior 200 mg, Cap, PO, bid, Routine, T;N, To be given at 0600 and Draw level prior cyclosporine (Sandimmune) 25 mg, Cap, PO, bid, Routine, T;N, To be given at 0600 and Draw level prior cyclosporine (Sandimmune) 50 mg, Cap, PO, bid, Routine, T;N, To be given at 0600 and Draw level prior cyclosporine (Sandimmune) 75 mg, Cap, PO, bid, Routine, T;N, To be given at 0600 and Draw level prior cyclosporine (Sandimmune) 100 mg, Cap, PO, bid, Routine, T;N, To be given at 0600 and Draw level prior cyclosporine (Sandimmune) 200 mg, Cap, PO, bid, Routine, T;N, To be given at 0600 and Draw level prior mycophenolate mofetil (Cellcept) 1000mg, Tab, PO, bid, Routine, T;N, To be given at 0600 and 1800 mycophenolate mofetil (Cellcept) 750 mg, Cap, PO, bid, Routine, T;N, To be given at 0600 and 1800 mycophenolate mofetil (Cellcept) 500 mg, Tab, PO, bid, Routine, T;N, To be given at 0600 and 1800 mycophenolate mofetil (Cellcept) 250 mg, Cap, PO, bid, Routine, T;N, To be given at 0600 and 1800 mycophenolic acid ( Myfortic) 720 mg, EC Tab, PO, bid, Routine, T;N, To be given at 0600 and 1800 mycophenolic acid ( Myfortic) 540 mg, EC Tab, PO, bid, Routine, T;N, To be given at 0600 and 1800 mycophenolic acid ( Myfortic) 360 mg, EC Tab, PO, bid, Routine, T;N, To be given at 0600 and 1800 mycophenolic acid ( Myfortic) 180 mg, EC Tab, PO, bid, Routine, T;N, To be given at 0600 and 1800 azathioprine (Imuran) 50 mg, Tab, PO, Qday, Routine, T;N, To be given at 1800 azathioprine (Imuran) 100 mg, Tab, PO, Qday, Routine, T;N,To be given at 1800 Transplant Steroid Taper Plan prednisone 5 mg, Tab, PO, Qday, Routine, T;N, To be given at methylprednisolone 500mg, Injection, IV Push, once, Routine, T;N methylprednisolone 250mg, Injection, IV Push, once, Routine, T;N Anti-Infective Medications valganciclovir 900 mg, Tab, PO, wb/s, Routine, T;N, CMV treatment valganciclovir 900 mg, Tab, PO, ws, Routine, T;N, CMV prophylaxis/treatment valganciclovir 450 mg, Tab, PO, ws, Routine, T;N, CMV prophylaxis/treatment fluconazole 200 mg, Tab, PO, QDay, Routine, T; N, fungal prophylaxis clotrimazole 10 mg, Tab, PO, pchs, Routine, T; N, fungal prophylaxis nystatin 5 ml, Oral Susp, pchs, Routine, T; N, swish and swallow sulfamethoxazole-trimethoprim 80 mg, Tab, PO, hs, Routine, T;N, Dose expressed as mg of trimethoprim (Septra/Bactrim) NOTE: If allergic to Sulfa place order below: dapsone 25 mg, Tab, PO, Qday, Routine, T,N Page 4 of 8

5 [R] = will be ordered Physician Orders ADULT Blood Pressure Medications metoprolol 12.5 mg, Tab, PO, bid, Routine, T;N, Hold for SBP less than 110mmHg, HR less metoprolol 25 mg, Tab, PO, bid, Routine, T;N, Hold for SBP less than 110mmHg, HR less than 60 bpm metoprolol 50 mg, Tab, PO, bid, Routine, T;N, Hold for SBP less than 110mmHg, HR less than 60 bpm metoprolol 100 mg, Tab, PO, bid, Routine, T;N, Hold for SBP less than 110mmHg, HR less metoprolol 150 mg, Tab, PO, bid, Routine, T;N, Hold for SBP less than 110mmHg, HR less metoprolol 200 mg, Tab, PO, bid, Routine, T;N, Hold for SBP less than 110mmHg, HR less metoprolol extended release 25 mg, Tab, PO, Qday, Routine, T;N, Hold for SBP less than 110mmHg, HR less metoprolol extended release 50 mg, Tab, PO, Qday, Routine, T;N, Hold for SBP less than 110mmHg, HR less metoprolol extended release 100 mg, Tab, PO, Qday, Routine, T;N, Hold for SBP less than 110mmHg, HR less metoprolol extended release 200 mg, Tab, PO, Qday, Routine, T;N, Hold for SBP less than 110mmHg, HR less labetalol 100 mg, Tab, PO, bid, Routine, T;N, Hold for SBP less than 110mmHg, HR less Blood Pressure Medications continued labetalol 200 mg, Tab, PO, bid, Routine, T;N, Hold for SBP less than 110mmHg, HR less labetalol 300 mg, Tab, PO, bid, Routine, T;N, Hold for SBP less than 110mmHg, HR less labetalol 400 mg, Tab, PO, bid, Routine, T;N, Hold for SBP less than 110mmHg, HR less labetalol 600 mg, Tab, PO, bid, Routine, T;N, Hold for SBP less than 110mmHg, HR less carvedilol mg, Tab, PO, wb/s, Routine, T;N, Hold for SBP less than 110mmHg, HR less carvedilol 6.25 mg, Tab, PO, wb/s, Routine, T;N, Hold for SBP less than 110mmHg, HR less carvedilol 12.5 mg, Tab, PO, wb/s, Routine, T;N, Hold for SBP less than 110mmHg, HR less carvedilol 25 mg, Tab, PO, wb/s, Routine, T;N, Hold for SBP less than 110mmHg, HR less atenolol 25 mg, Tab, PO, qday, Routine, T;N, Hold for SBP less than 110mmHg, HR less atenolol 50 mg, Tab, PO, qday, Routine, T;N, Hold for SBP less than 110mmHg, HR less 110, HR less than 60 atenolol 100 mg, Tab, PO, qday, Routine, T;N, Hold for SBP less than 110mmHg, HR less Page 5 of 8

6 Physician Orders ADULT [R] = will be ordered Blood Pressure Medications continued amlodipine 5 mg, Tab, PO, qday, Routine, T;N, Hold for SBP less than 120mmHg amlodipine 10 mg, Tab, PO, qday, Routine, T;N, Hold for SBP less than 120mmHg NIFEdipine extended release 30 mg, Tab, PO, qday, Routine, T;N, Hold for SBP less than 120mmHg NIFEdipine extended release 60 mg, Tab, PO, qday, Routine, T;N, Hold for SBP less than 120mmHg NIFEdipine extended release 90 mg, Tab, PO, qday, Routine, T;N, Hold for SBP less than 120mmHg NIFEdipine extended release 120 mg, Tab, PO, qday, Routine, T;N, Hold for SBP less than 120mmHg clonidine 0.1 mg, Tab, PO, bid, Routine, T;N, Hold for SBP less than 120mmHg, HR less than clonidine 0.2 mg, Tab, PO, bid, Routine, T;N, Hold for SBP less than 120mmHg, HR less than clonidine 0.3 mg, Tab, PO, bid, Routine, T;N, Hold for SBP less than 120mmHg, HR less than clonidine 0.1 mg, Tab, PO, tid, Routine, T;N, Hold for SBP less than 120mmHg, HR less than clonidine 0.2 mg, Tab, PO, tid, Routine, T;N, Hold for SBP less than 120mmHg, HR less than clonidine 0.3 mg, Tab, PO, tid, Routine, T;N, Hold for SBP less than 120mmHg, HR less than hydralazine 25 mg, Tab, PO, tid, Routine, T;N, Hold for SBP less than 120mmHg hydralazine 50 mg, Tab, PO, tid, Routine, T;N, Hold for SBP less than 120mmHg hydralazine 75 mg, Tab, PO, tid, Routine, T;N, Hold for SBP less than 120mmHg hydralazine 100 mg, Tab, PO, tid, Routine, T;N, Hold for SBP less than 120mmHg clonidine 0.1 mg, Tab, PO, q4h, PRN Hypertension, Routine, T;N, PRN SBP greater than 160 mmhg or DBP greater than 90 mmhg NOTE: If allergic to clonidine place order below: hydralazine 10 mg, Injection, IV Push, q4h, PRN Hypertension, Routine, T;N, PRN SBP greater than 160 mmhg or DBP greater than 90 mmhg Other Medications NOTE: Order Transplant Sliding Scale Insulin Protocol below as appropriate including if Transplant Steroid Taper has been ordered. Transplant Sliding Scale Insulin Protocol aspirin 81 mg, EC Tablet, PO, Qday, Routine, T; N aspirin 325 mg, EC Tablet, PO, Qday, Routine, T; N famotidine 20 mg, Tab, PO, QDay, Routine, T; N famotidine 20 mg, Tab, PO, bid, Routine, T; N esomeprazole 40 mg, Cap, PO, Qday, Routine, T; N metoclopramide 5 mg, Tab, PO, ac, Routine, T;N metoclopramide 5 mg, Tab, PO, achs, Routine, T;N metoclopramide 10 mg, Tab, PO, ac, Routine, T;N metoclopramide 10 mg, Tab, PO, achs, Routine, T;N magnesium oxide 400 mg, Tab, PO, wb/s, Routine, T;N magnesium oxide 800 mg, Tab, PO, wb/s, Routine, T;N calcium (as carbonate)-vitamin D tab, Tab, PO, wb/s, Routine, T;N mg-200 intl units oral tablet Multiple Vitamins with Minerals oral 1 tab, Tab, PO, ws, Routine, T;N tablet furosemide 40 mg, Tab, PO, qday, Routine, T;N Page 6 of 8

7 [R] = will be ordered Physician Orders ADULT Laboratory CBC STAT, T;N, once, Blood Comprehensive Metabolic Profile STAT, T;N, once, Blood Magnesium Level STAT, T;N, once, Blood Phosphorus Level STAT, T;N, once, Blood Prothrombin Time ( PT/INR) STAT, T;N, once, Blood Partial Thromboplastin Time ( PTT) STAT, T;N, once, Blood Amylase Level STAT, T;N, once, Blood Lipase Level STAT, T;N, once, Blood Blood Culture Time Study, T;N, q5min, x2 occurences, Specimen Source: Peripheral Blood CMV Whole Bld by PCR STAT, T;N, Blood, This test is only performed on WHOLE BLOOD. Quantitative Transplant ATP by Cylex STAT, T;N, once, Blood BK Virus DNA, Quantitative PCR STAT, T;N, once, Blood BK Virus DNA, Quant PCR, UR STAT, T;N, once, Urine, Nurse Collect UA STAT, T;N, once, Urine, Nurse Collect Urine Drug Screen (UDAS) STAT, T;N, once, Urine, Nurse Collect Urine Culture ( Urine C&S) STAT, T;N, once, Urine, Nurse Collect Gram Stain STAT, T;N, once, Sputum, Nurse Collect Occult Blood, Stool STAT, T;N, once, Stool, Nurse Collect C Diff Toxin B Gene by PCR STAT, T;N, once, Stool, Nurse Collect NOTE: AM Labs Lipid Profile T+1; 0400, once, Blood C-Peptide T+1; 0400, once, Blood Hemoglobin A1C T+1; 0400, once, Blood Rapamycin Level T+1; 0400, once, Blood Rapamycin Level Routine, T+1;N, qam, Blood Rapamycin Level Routine, T;N, MonThu, Blood FK506 Level ( tacrolimus level) Routine, T+1;N, qam, Blood Cyclosporine Level Routine, T+1;N, qam, Blood CBC Routine, T+1;N, qam, Blood Prothrombin Time ( PT/INR) Routine, T+1;N, qam, Blood Comprehensive Metabolic Profile Routine, T+1;N, qam, Blood Comprehensive Metabolic Profile Routine, T;N, MonThu, Blood BMP Routine, T+1;N, qam, Blood Magnesium Level Routine, T+1;N, qam, Blood Phosphorus Level Routine, T+1;N, qam, Blood Amylase Level Routine, T+1;N, qam, Blood Lipase Level Routine, T+1;N, qam, Blood NOTE: If peritoneal dialysis catheter present, place order below: Body Fluid Profile STAT, T;N, Peritoneal Fluid, Nurse Collect Diagnostic Tests US Kidney Transplanted w/wo Dup T;N, Reason for Exam:, STAT, stretcher Doppler (Renal (Transplant) US) Chest 1VW Frontal ( Chest 1 VW ) T;N, Reason:, Routine, Transport: Portable Electrocardiogram( EKG) Start at T;N, Priority: STAT, Reason for Exam: Page 7 of 8

8 [R] = will be ordered Physician Orders ADULT Consults/Notifications Notify Physician For Vital Signs Of T;N, Who: Transplant Nephrology Fellow, BP Systolic > 180, BP Diastolic > 90, BP Systolic < 100, BP Diastolic < 60,Celsius Temp > 38.3, Urine Output < 400 ml/ 8 hours, Difference between Lying and Standing BP > 40, Oxygen Sat < 94. Notify Physician -Once T;N, Who: Surgery Transplant Fellow, For: upon arrival to unit Notify Physician -Once T;N, Who: Transplant Nephrology Fellow, For: upon arrival to unit Pharmacy Consult T;N, Reason:Transplant patient arrival, Special Instructions: Transplant Pharmacy Specialist Dietitian Consult T;N, Type of Consult: Other, Nutritional Assessment and Recommendations Diabetes Teaching Consult T;N, Routine, For: Diabetic Education Medical Social Work Consult T;N, Reason for Consult : Date Time Physician's Signature MD Number Page 8 of 8