Pediatric Order Set 0 through 16 yrs age Addressograph Stamp
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1 Date Pediatric Order Set 0 through 16 yrs age Time 1. [ ] Place in Observati: [ ] Mitored Telemetry Bed [ ] Unmitored Bed OR [ ] Admit to Inpatient: [ ] Med-Surg Telemetry Mitor [ ] Med-Surg 2. Diagnosis: Admit to: Dr 3. Code Status: [ ] See Completed Code Sheet * ote: o Code verbal order may ly be taken in emergency situatis 4. Labs: [ ] CBC, U/A, Chem 7, PT, PTT [ ] Amylase and lipase [ ] Blood Cultures times site(s) [ ] CMP [ ] BP [ ] Fasting Lipid Profile (if not de as outpatient- within last 3 mths) [ ] Throat Culture [ ] Other [ ] MRSA screens for all patients readmitted within 7 days, nursing home patients, persal care home residents and group home residents. (Maintain ctact precautis until negative result obtained.) 5. Studies: [ ] Portable Chest X-Ray arrival if not de in ER 6. O2 via ; L/min.; [ ] Ctinuous [ ] prn [ ] Maintain SaO2 % 7. SVs: [ ] Dueb Q hr [ ] W/A [ ] prn [ ] Other Q hr [ ] W/A [ ] prn 8. Vital Signs [ ] Med-Surg (4hr) [ ] Observati (q 2hr) [ ] euro Signs q hr 9. Activity: [ ] Absolute bed rest [ ] B.S. Commode [ ] BRP [ ] Elevate HOB [ ] Ad lib 10. Diet: [ ] PO [ ] Clear Liquids [ ] Age Appropriate Regular Diet [ ] ADA Diet Calories 11. Chart I & O [ ] 12. Weigh Daily [ ] 13. IV soluti: Rate [ ] Saline Lock with routine flush 14. Csults: [ ] Dr [ ] Dietary [ ] SS [ ] PT [ ] OT Physician Signature
2 Pediatric Admissi Order Set Allergies Date/Time Code Key Rx Prescripti Bottle? Unsure or Questiable Ph Pharmacist Called ER ER Documentati L Written or Printed List V Verbalized List Patient Height Patient Weight lbs = KG Pre-existing [ ] Renal Impairment [ ] Hypertensi [ ] Diabetes Mellitus Cditis: [ ] Liver Impairment [ ] Pregnant [ ] Breast Feeding Pre-admissi Medicatis: Include all over-the-counter and herbal medicatis. All Medicatis must be reviewed prior to discharge and circled es or o C O D E while Inpatient Date/Time Medicatis (All medicati calculatis to be checked by two Rs and calculated Kg weight) [ ] Tylenol Tablets / Elixir / Suppository mg po/rectal q 4 hours prn Alternate with [ ] Ibuprofen Tablets or Elixir mg po q 6 hours prn For pain or temperature greater than Date & Time GEERAL ORDERS Date & Time MEDICATIO ORDERS
3 Date & Time GEERAL ORDERS Date & Time MEDICATIO ORDERS Allergies
4 Pediatric Vital Signs (Please place this page in Bedside Chart for vital sign reference) Vital signs remain relatively cstant throughout adult life. However, as infants and children grow and age, the normal range changes. Refer to the two following tables for normal vital signs for this pediatric admissi. Age (years) Respiratory Rate (breaths/min) Heart Rate (beats/min) < > Lower Limits of Systolic Pressure 0-28 Days: 60mmHg 1-12 Mths: 70mmHg 1-10 ears: 70mmHg + (2 times age in years) Age Heart Rate Blood Pressure (mmhg) Respiratory Rate (breaths/min) Premature / mo / mo / mo / yr / yr / yr / >12 yr / Source: 03/18/11
5 Pediatric Orders Date Time 1. patient all medicatis circled es and enter Medicati Card 2. patient to: [ ] Home [ ] Home Health [ ] Hospice [ ] Other: 4. Diet Instructis: [ ] As tolerated [ ] Low sodium diet [ ] If diabetic, Calorie ADA Diet [ ] Other: 5. Instructis: [ ] Return to School / / [ ] ote Provided [ ] Homebound Schooling 6. Treatments / Other 7. Outpatient Lab: [ ] es [ ] o If yes Specify Type Date / Time 8. Home Oxygen [ ] Oxygen Liter Flow /min 9. Appointment with Dr. Locati Please call office immediately to schedule a return visit in Phe umber 10. Report to Physician: [ ] Short of Breath [ ] Fever [ ]Swelling [ ]ausea [ ]Vomiting [ ]Pain [ ] Excessive Diarrhea 11. [ ] Fax Orders and Patient Medicati List to Office. 12. [ ] Patient and family discharge educati 13. Vaccine Status: [ ] Follow-up in office for a vaccinati if patient is a candidate and did not receive while in the hospital Revised 2/12 Physician Signature
Myocardial Infarction Order Set
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Physician s Order Form. Physician s Order Form. Telemetry/Progressive Care Orders. Continued on next page. >>>>>>> Continued on next page.
DATE: TIME: DATE TIME INTRAVENOS FLID and MEDICATION Status: Admit to Telemetry Admit to Progressive Care nit Transfer to Progressive Care nit Note: Discontinue Previous Orders Transfer to Telemetry nit
Acute Stroke with Alteplase Administration Order Set
Review Due Date: 2017 October PATIENT CARE DERS Weight: Adverse Reactions or Intolerances Drug No Yes (list) Food No Yes (list) _ Latex No Yes Admission Admit to Neurology service: Dr. Critical Care Diagnosis:
IDPH ESF-8 Plan: Pediatric and Neonatal Surge Annex Sample Pediatric Admission Orders 2015
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Physician Orders ADULT Order Set: Respiratory Failure Orders
[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
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Admit date (YYYY/MM/DD): Cardiologist On-Call: Diagnosis: Lab Tests. CBC, Electrolytes, Urea, Creatinine, Glucose, INR, PTT, Urinalysis
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PEDIATRIC ASTHMA INPATIENT CARE MAP
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ST. DOMINIC-JACKSON MEMORIAL HOSPITAL JACKSON, MISSISSIPPI
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Physician Orders. PED Endocrine General Admit Plan [X or R] = will be ordered unless marked out. [ ] No known allergies
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*111* attach patient label here
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
* * FORM REV. 02/2019 Page 1 of 4. TNKASE (tenecteplase) / ACUTE STEMI ORDERS SCHEDULED MEDICATIONS:
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SN Visit Note. Vital Signs. Blood Sugar. Oxygen. Allergies. Pain Assessment. Visit Date: Episode Date: Patient Name: Patient ID:
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(Page 1 of 5) Diagnosis: Procedure: Right Total Knee Replacement Unicompartmental Knee Left Total Hip Revision Total Shoulder
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