UNIVERSITY OF CALIFORNIA, DAVIS MEDICAL CENTER SACRAMENTO, CALIFORNIA
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1 ENT ADMISSION ORDERS TO TOWER 7 MSICU Attending: Fellow: Resident: Diagnosis: Surgery: Isolation: Allergies: (Food & Med.) Respiratory Settings: FiO2 SIMV TV PS PEEP. O2 Therapy L, %, NP Mask Cupula Heated mist Cool mist Wean from ventilator to keep SaO2 >92%, ph >7.32 & RR <30 Line Care: A-line Swan-Ganz IV Fluid: Activity: Head of bed at 30 degrees. Bed rest X 24h. Then OOB q shift & prn when hemodynamically stable. NPO: NG to int. wall suction X 24h then clamp. DO NOT REPOSITION Secure w/tape. TED/SCD. (May D/C when ambulating.) Medications: ASA 325mg NG/PO daily Docusate 100 mg NG/PO q 12h. Famotidine 20 mg IV/NG/PO q 12h. MVI 1 amp IV/NG/PO daily X 7 day. Folate 1 mg IV/NG/PO daily X 7 day. Thiamine 100 mg IV/NG/PO daily X 7 day. Lacrilube OU q hs. Artificial tears q 2h while awake. A (09-04) OTOLARYNGOLOGY HEAD AND NECK SURGERY PHYSICIANS ORDERS PAGE 1 OF 4- MR02/94323
2 MEDICATIONS: See antibiotics sheet. PRN MEDICATIONS: PCA per Anesthesia Pain Service. Lorazapam 1-2 mg IV q 2-4h prn agitation. Morphine Sulfate 2-6 mg IV q 1-2h prn pain. Acetominophen with Codeine elixir ml q 4-6h prn pain. Acetominophen 650 mg NG/PR q 6h prn T >38.5º C. Diphenhydramine mg IV/NG q 6h prn itching. Metaclopramide 10 mg IV q 4h prn nausea/vomiting. Phenergan 12.5 mg-25 mg IV q 6h prn nausea/vomiting. MOM ml po daily prn No BM (use first) Ducolax supp. PR prn No BM (if no result with MOM) Fleets Enema daily prn No BM (if no result with above) K series: Call H.O. for K < 3.0 or > 5.5. (Redraw post coverage) K < 3.9 give 10 meq KCl IV X 3. K < 3.5 give 10 meq KCl IV X 4. Magnesium series: (Redraw post coverage) Mg < 1.8 give 1 Gm MgSO4 IV Mg < 1.5 give 2 Gm MgSO4 IV Calcium series: (Redraw post coverage) Calcium Gluconate 1amp IV for ion Ca <. LABS AND X-RAY: Chest X-Ray in AM X 1 and in RR. CBC, BMP, Ca, Mg & Phos. q AM X 3 days and in RR. CMP q Monday and Thursday ABG prn A (09-04) OTOLARYNGOLOGY HEAD AND NECK SURGERY PHYSICIANS ORDERS PAGE 2 OF 4- MR02/94323
3 ROUTINE CARE: Strict intake and output. Foley to gravity drain. Weight daily. Vital signs per ICU routine. Call HO SBP<180>80;DBP<90;T>38.5 C; HR<50 >110; RR>25; UO<30ml hr; SaO2<92% WOUND CARE: Wound care with H2O2 followed by NS wash to remove crusts. q 6h & prn Apply Bacitracin ointment q 12h X 2 days then D/C. JP drains to bulb suction. (If bulb not holding suction switch to low wall suction) Record drains separately. Strip drains q 1-2h for patency. (tape tubing securely to skin) STSG thigh donor site. Change Aquacell daily and prn breakthrough drainage. Use Hydrogel when No drainage daily and prn FLAP CARE: Type: Check capillary refill q 1h X 24h Then q 4h. (call HO for) Any change in flap/reconstruction capillary refill. Fluid collection under flap. Air leak around drain insertion site. Unusual drainage from drain (including frothy) Incision becomes red, develops pustules, is edematous or dehiscent Refer to free flap order sheet. AIRWAY CARE: Routine laryngectomy/tracheostomy care q 8h and prn. Instill.9 NS pillows q 1-2h. Deflate cuff when off vent unless on aspiration precautions. Routine laryngectomy care q 8h and prn. Instill.9 NS pillows q 1-2h. A (09-04) OTOLARYNGOLOGY HEAD AND NECK SURGERY PHYSICIANS ORDERS PAGE 3 OF 4- MR02/94323
4 ORAL CARE: ½ st.h202 &.9 NS or Peridex q 4h. Do not suction or clean directly over internal oral suture lines. Consults: Anesthesia Pain Service. (MD to call.) Critical Care Medicine. (MD to call.) ENT Speech Pathology. Call (voice mail) Nutrition. Physical Therapy. IV Therapy for PICC line insertion call Nights & weekends call (voice mail). Transfusion Orders: Call HO Hgb < or Hct < for transfusion orders. Premedicate with: a) Acetominophen 650mg NG/PR x 1. b) Diphenhydramine 50mg IV/NG x 1. Nursing and Patient Education: MPER for total laryngectomy/partial laryngectomy. MPER for oral-facial cancer Advance Directive. Attending Physicians Name: PI# Beeper. Ordering Physicians Name: PI# Beeper. A (09-04) OTOLARYNGOLOGY HEAD AND NECK SURGERY PHYSICIANS ORDERS PAGE 4 OF 4- MR02/94323
5
Physician Orders ADULT: Head and Neck Postoperative Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase, Phase: Head and Neck Postoperative Phase, When to Initiate: Head and Neck Post Operative Phase, Monitor and Record T,P,R,BP,
Physician Orders PEDIATRIC: LEB Kidney Transplant Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: LEB Kidney Transplant Post Op Phase, When to Initiate: LEB Kidney Transplant Post Op Phase Admission/Transfer/Discharge
Physician Orders ADULT: Kidney-Panc/PancTransplant Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase T;N, Phase: Kidney-Panc/Panc Transp Post Op Phase, When to Initiate: Kidney-Panc/Panc Transp Post Op Phase Vital Signs Vital
Physician Orders PEDIATRIC: LEB NEURO SURG Surgical Spine Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: LEB Neuro Surg Spine Postop Phase, When to Initiate: LEB Neuro Surgical Spine Post Op Phase Admission/Transfer/Discharge
PEDIATRIC SPINE SURGERY POST-OP PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care Patient Activity Bedrest Maintain Surgical Drain Maintain JP Drain, Measure Output q12h, and PRN Convert IV to INT when tolerating
Physician Orders PEDIATRIC: LEB Oral Maxillofacial Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: LEB Oral Maxillofacial Postop Phase, When to Initiate: LEB Oral Maxillofacial Post Op Phase Admission/Transfer/Discharge
ALL orders are active unless: 1. Order is manually lined through to inactivate 2. Orders with check boxes ( ) are unchecked DRUG AND TREATMENT ORDERS
DRUG AND TREATMENT Intubation Phase Notify Therapy for STAT intubation Medications SUB Rapid Sequence Induction (SUB)* ***Reminder: Order SUB Rapid Sequence Induction (SUB) on a separate form*** lidocaine
PICU ADMIT DKA PLAN - Phase: Begin Immediately
- Phase: Begin Immediately Diagnosis Weight Allergies Admit/Discharge/Transfer Patient Status Requested Location: PICU, Pt Status: Inpatient (LOS > 2 midnights) Requested Location: PICU, Pt Status: Observation
POST-OP CARDIAC SURGERY PHYSICIAN S ORDER SHEET USE BALLPOINT PEN ONLY. CARDIAC INTENSIVE CARE UNIT
PHYSICIAN S SHEET Automatically Activate, if not in agreement, cross out and initial Activated by Checking Box ALLERGIES: None known YES Patient s Height: Patient s Weight: ALL MEDICATION and INTRAVENOUS
Bariatric Surgery Post Op Day Version 2 Approved 11/13/2017
Patient Name: Diagnosis: Allergies with reaction type: Bariatric Surgery Post Op Day Version 2 Approved 11/13/2017 Diagnosis Preferred Location/Unit Surgical ICU Code Status: Full Code Activity Ambulate
ENT THYROIDECTOMY/PARATHYROIDECTOMY POST OP ADMIT PLAN - Phase: Begin Immediately/PACU
- Phase: Begin Immediately/PACU Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Pt Status:
ENT THYROIDECTOMY/PARATHYROIDECTOMY POST OP PLAN - Phase: Begin Immediately/PACU
- Phase: Begin Immediately/PACU PHYSICIAN S Diagnosis Weight Allergies Laboratory Calcium Level STAT Outpatient/PACU, T;N PTH Intact STAT Outpatient/PACU, T;N 1 of 7 - Phase: When Patient Arrives to Room
PEDIATRIC SPINE SURGERY POST-OP PLAN - Phase: Pediatric Spine Surgery General Orders
- Phase: Pediatric Spine Surgery General Orders PHYSICIAN S Diagnosis Weight Allergies Patient Care Patient Activity Bedrest Maintain Surgical Drain Maintain JP Drain, Measure Output q12h, and PRN Convert
Card Open Heart POD1 POD3 Plan Post Op Day 1
Day 1 PHYSICIAN S Weight Allergies Admit/Discharge/Transfer Transfer Patient Transfer to: Floor, Pt Status: Inpatient (LOS > 2 midnights) Vital Signs q2h, POD 1 Vital Signs q2h for 24 hours then per unit
Initials * Page 1 of 6. (place patient label here) Patient Name: Diagnosis: Allergies with reaction type:
Patient Name: Diagnosis: Allergies with reaction type: Orthopedic Upper Ext Post Op Version 3 4/20/17 Patient Placement General Diagnosis/Procedure: Preferred Location/Unit Ortho/Neuro General Medical
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
Available ONLY at: BMC-B BMC-D BMC-N BMC-S Intubation Phase Notify Therapy for STAT intubation SUB Rapid Sequence Induction(SUB)* ***The above subphase is available at the end of the powerplan under the
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
Patient: Becky Smith DOB: 01/26/XXXX Age: 5 y/o Attending: Dr. D. Miles Allergies: NKA MR#: 203. Patient Chart #203 Becky Smith
Patient Chart #203 Becky Smith 1 Property of CSCLV CSCLV Rev: 06/04/2018 Chief Complaint: Abdominal pain. Informant: Parents. HISTORY & PHYSICAL HPI: Ill looking patient, healthy until 2 days ago when
USD Healthcare Center
Sally Nelson DOB: 11/29/1941 HCP: Dr. Winters Age: 68 yrs. Height: 67 in. (170 cm) Weight: 145 lbs. (65.9 kg.) MR# PCS62800 Gender: F No Known Allergies Allergies & Sensitivities PCN, Sulfa Diagnosis:
1. Attending Physician: Dr Syn Pager: Cell: Co-Morbidities:
BARIATRIC SURGERY IMMEDIATE POST-OP PLAN (Includes Post Op Day 1) Denotes order requirement Antibiotic administered in the OR at: 1. Attending Physician: Dr Syn Pager: 740-6545 Cell: 438-9415 2. To remain
IDPH ESF-8 Plan: Pediatric and Neonatal Surge Annex Sample Pediatric Admission Orders 2015
Purpose: To provide guidance to practitioners caring for pediatric patients who need inpatient hospital care during a disaster. Disclaimer: This guideline is not meant to be all inclusive, replace an existing
A UMC Health System Performance Improvement Initiative for use in all units where patients with are admitted for Surgical Care Improvement Project.
ENDOLUMINAL AAA POST-OP PLAN A UMC Health System Performance Improvement Initiative for use in all units where patients with are admitted for Surgical Care Improvement Project. *Denotes guideline requirement
Organ Donor Management Recommended Guidelines ADULT CARDIAC DEATH (DCD)
Date: Time: = Always applicable = Check if applicable ADMISSION INSTRUCTIONS Move to Comfort Care Note in chart. Contact initiated with BC Transplant Consent for Organ Donation obtained Code Status: Full
LIFEGIFT BRAIN DEATH PLAN
Diagnosis Weight Allergies Admit/Discharge/Transfer ***THIS PLAN IS TO BE ED ONLY ON THE LIFEGIFT ENCOUNTER, WITH DR LIFEGIFT AS THE ATTENDING*** Patient Status Pt Status: Inpatient (Inpatient only procedure)
Standard Precautions Droplet Precautions Standard Precautions Contact Precautions Droplet Precautions Standard Precautions Neutropenic Precautions
Unique Plan Description: Neurosurgery Subarachnoid Hemorrhage Admission Adult Plan Selection Display: Neurosurgery Subarachnoid Hemorrhage Admission Adult PlanType: Medical Version: 10 Begin Effective
Total Hip Replacement Post Op Version 4 4/20/17
Patient Name: Diagnosis: Allergies with reaction type: Total Hip Replacement Post Op Version 4 4/20/17 Patient Placement General Diagnosis/Procedure: Preferred Location/Unit Ortho/Neuro General Medical
Organ Donor Management Recommended Guidelines ADULT Brain Death (NDD)
Date: Time: = Always applicable = Check if applicable ADMISSION INSTRUCTIONS Neurological Determination of Death (NDD) has been performed by at least 2 licensed physicians Contact initiated with BC Transplant
Orders OR 1 Vulvectomy Post-op Orders
Orders OR 1 Vulvectomy Post-op Orders Immediate Post-op Admit to 8B Service: Attending: Diagnosis: S/P Complete Radical Vulvectomy Condition: Stable Allergies: Activity: Complete bedrest, do not elevate
Physician Orders ADULT: Vascular Surgery AAA Repair Open Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: AAA Repair Open Postop Phase, When to Initiate: Initiate Powerplan Phase Phase: Mechanically Ventilated Patients Phase,
OB/GYN POSTPARTUM VAGINAL DELIVERY PLAN
OB/GYN POSTPARTUM VAGINAL DELIVERY PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Patient Activity Up Ad Lib/Activity as Tolerated Bedrest STRICT Bedrest Up to
Neurosurgery Pre-Op [1710] Patient Name MRN. General. Nursing. Case Request [ ] Case request operating room Scheduling/ADT, Scheduling/ADT [ ] Other
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Neurosurgery Pre-Op [1710] Patient Name MRN General Case Request [ ] Case request operating room Scheduling/ADT, Scheduling/ADT Inpatient Only Procedure (Single Response) ( ) Admit to Inpatient Diagnosis:
Physician Orders ADULT: Vascular Surgery AAA Endovascular Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: AAA Endovascular PACU Phase, When to Initiate: Initiate Powerplan Phase Phase: Mechanically Ventilated Patients Phase,
GENERAL SURGERY POST-OP PLAN
GENERAL SURGERY POST-OP PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest Bedrest Bathroom
Optimize vent weaning and SBT outcomes. Identify underlying causes for SBT failures. Role SBT and weaning protocol have in respiratory care
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GENERAL SURGERY PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest Bedrest Bathroom Privileges
(Page 1 of 5) Diagnosis: Procedure: Right Total Knee Replacement Unicompartmental Knee Left Total Hip Revision Total Shoulder
(Page 1 of 5) Allergies/Sensitivities/Reactions: Height: Inches cm Weight: Kg Pounds = Automatic = Physician s option, Check off to Order Diagnosis: Procedure: Right Total Knee Replacement Unicompartmental
EPIDURAL / INTRATHECAL POST-OP PLAN
EPIDURAL / INTRATHECAL POST-OP PLAN Diagnosis Weight PHYSICIAN S Allergies Patient Care Vital Signs Per Unit Standards, PLUS check and record RR q1h x 12, then q2h x 6, until 24h following narcotic administration.
Physician Orders PEDIATRIC: LEB Stroke Admit Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: LEB Stroke Admit Phase. When to Initiate: LEB Stroke Admit Phase Admission/Transfer/Discharge Patient Status Initial
Gabapentin Research Pain Study for Ortho Total Knee Replacement Post-Op Plan - PACU Ortho Phase
Total Knee Replacement Post-Op Plan - PACU Ortho Phase Diagnosis Weight Allergies Admit/Discharge/Transfer Patient Status Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights) Patient Condition
CARING FOR THE TRACHEOSTOMISED PATIENT: WHAT TO LOOK OUT FOR
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ADULT POST NEUROLOGIC INTERVENTION ORDERS 2 of 4
9 Actual 9 Estimated DOWNTIME INTERVENTION 1 of 4 Weight kg 9 Actual 9 Estimated Height cm ALLERGIES: REFER TO ALLERGY PROFILE/ POWERCHART Admit to Dr.: Bed Type: Dx: ( ) Check, circle and/or fill in all
OB/GYN POSTPARTUM VAGINAL DELIVERY PLAN
OB/GYN POSTPARTUM VAGINAL DELIVERY PLAN PHYSICIAN S Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Discharge Anticipated in 24 Hour (Patient Discharge Anticipated in 24 Hours) Patient
UMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis
Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards q12h q12h, Temperature Only - Every Shift and PRN Patient Activity Assist as Needed, Bed Position: As Tolerated, elevate to patient
Physician Orders ADULT: Ortho Total Joint Plan
Initiate Orders Phase Non Categorized R Powerplan Open Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: Ortho Total Joint Preop Phase, When to Initiate: Other-See Special Instructions, initiate
Pediatric Intensive Care Unit (PICU) Pediatric Diabetic Ketoacidosis (DKA) Admission Order Set
Discontinue all previous orders Weight: kg DKA admit order set is for initial management Ongoing management required based on frequent reassessment of TFI, fluid balance and lab results. Admit to PICU
PEDIATRIC LIFEGIFT BRAIN DEATH PLAN
PHYSICIAN S Diagnosis Weight Allergies Admit/Discharge/Transfer THIS PLAN IS TO BE ED ONLY ON THE LIFEGIFT ENCOUNTER, WITH DR LIFEGIFT AS THE ATTENDING. Patient Status Pt Status: Inpatient (Inpatient only
ST. DOMINIC-JACKSON MEMORIAL HOSPITAL JACKSON, MISSISSIPPI
Date & Time TAVR Pre-Op Admission Clinical Pathway Page 1 of 3 1. Admit as INPATIENT to Dr.. For Surgery Today or Tomorrow 3. Diagnosis: 4. Allergies: Pharmacy Mnemonic: PRETAVR 5. Vital signs on arrival.
ST. DOMINIC-JACKSON MEMORIAL HOSPITAL JACKSON, MISSISSIPPI
Date & Time Post-Op Inpatient General Orthopedic Page 1 of 5 Pharmacy Mnemonic: POIGOP1 1. Admit as inpatient to Dr. 2.Diagnosis: 3.Admit to PACU and then to floor ICU 4.Radiology: AP Pelvis in PACU AP
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
Therapeutic Hypothermia for Post Cardiac Arrest Plan Initial Orders
Arrest Plan Initial Orders Weight Allergies Therapeutic Hypothermia Guidelines ***Required to continue with ordering Plan.*** Strict Intake and Output q1h, throughout cooling and re warming. Set Up for
1. Attending Physician: Resident/Fellow: 2. Consult
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- Phase: PACU Phase PHYSICIAN S Diagnosis Weight Allergies Communication Place Device at Bedside Confirm there are 3 x Aliquots of 0.2% Ropivacaine. 2 x Medfusion Infusion pumps. Confirm 3 x PF Aliquots
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IV Acetaminophen Pain Study for Neurosurgery Post Op Non ICU Admit Plan Begin Immediately/PACU
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NUR 215 Surgical Simulation
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GENERAL MEDICINE PLAN
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Policies & Procedures Title: ESOPHAGEAL TAMPONADE TUBE (MINNESOTA Tube) ASSISTING WITH INSERTION, CARE OF A PATIENT, ASSISTING WITH REMOVAL RNSP - RN Procedure I.D. Number: 1097 Authorization [x] Nursing
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All bedside percutaneously placed tracheostomies
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UROLOGY POST OPERATIVE PLAN Patient Label Here A UMC Health System Performance Improvement Initiative for use in all units where surgical patients receive care in support of Surgical Care Improvement Program
UMC Health System Patient Label Here PHYSICIAN ORDERS
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Physician Orders ADULT: Sickle Cell Inpatient Plan
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IR Central Venous Access [ ] Pre Procedure
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Height: cm Weight: kg Allergies: [ ] No known allergies [ ] Initiate Powerplan Phase T;N, Phase: LEB PICU Admit Phase Admission/Transfer/Discharge [ ] Admit Patient to Dr. [ ] Admit Status: [ ] Inpatient
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Enhanced Recovery Thoracic Surgery. Esophagus Pathway
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(Page 1 of 5) Code Status Full code Status/Admit/Transfer/Discharge Surgical Procedure(s) and date performed: Cardiologist: Cardiac Surgeon: Intensivist: Patient Care CMV status Recipient CMV status Donor
Physician Orders PEDIATRIC: LEB Ortho Accelerated Posterior Spinal Fusion Post Op Plan
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Spontaneous Breathing Trial and Mechanical Ventilation Weaning Process
Page 1 of 5 ASSESSMENT INTERVENTION Patient receiving mechanical ventilation Baseline ventilatory mode/ settings RT and RN to assess criteria 1 for SBT Does patient meet criteria? RT to initiate SBT Does
MECHANICAL VENTILATION PROTOCOLS
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ORTHO TOTAL KNEE REPLACEMENT POST-OP PLAN - Phase: PACU Ortho Phase
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EFFECTIVE DATE: 01/2007 REVISED: 07/2008, 6/11, 3/12, 8/12, 1/15. Purpose:
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UMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis
COPD PLAN UMC Health System PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care Vital Signs Per Unit Standards Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest
(31189) Hypothermia Initiation Phase One
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PICU CARD SURG Post Operative Cardiac Transplant Age LESS than 6 months (Page 1 of 5)
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