Myocardial Infarction Order Set
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- Barnard Whitehead
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1 Myocardial Infarcti Order Set Date Time 1. [ ] Inpatient: [ ] CCU [ ] PCU [ ] ICU 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, BMP, PT, PTT [ ] CPK, CK-MB, Tropin Admissi, q6 hrs. x 4 [ ] BrP [ ] Fasting Lipid Profile (if not de as outpatient- within last 3 mths) [ ] If patient Digoxin, obtain level if not de in ER [ ] 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: [ ] EKG [ ] EKG in AM [ ] EKG Daily X 3 [ ] EKG during episodes of Chest Pain. [ ] ECHO (if not de in last 6 mths) Reas: (Obtain Previous ECHO result) [ ] 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: [ ] ICU/CCU (q ¼ hr x 1; then q 2hr) [ ] PCU (q 2 hr x 4; then q.i.d.) 9. Activity: [ ] Absolute bed rest [ ] B.S. Commode [ ] BRP [ ] Elevate HOB Diet: [ ] Fluid Restricti to [ ] PO [ ] IV [ ] PO & IV 11. [ ] Chart I & O 12. [ ] Weigh Daily 13. IV soluti: Rate [ ] Saline Lock with routine flush 14. Csults: [ ] Cardiology [ ] Dr [ ] Dietary [ ] SS [ ] PT [ ] OT 15. Cardiopulmary: [ ] Smoking Cessati [ ] Outpatient Cardiac Rehab Physician Signature
2 Allergies Code Key Rx Prescripti Bottle? Unsure or Questiable Ph Pharmacist Called ER ER Documentati L Written or Printed List V Verbalized List Date/Time 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 Standard Medicatis: Antacid: [ ] Mylanta 30ml po prn tid ausea: [ ] Zofran 4 mg IV q 6 hr prn Headache/fever: [ ] Tylenol 1000mg po q 6 hr prn Laxative: [ ] MOM 30 ml po prn Sleep: [ ] Ambien 5 mg po q hs prn Sedati: [ ] Ativan 0.5 mg po q 4 hr prn [ ] Xanax 0.25 mg po q 4 hr prn Chest Pain: [ ] TG 0.4 mg SL q 5 min. x 3 prn and call MD. icotine Replacement: [ ] icotine Patch 21 mg [ ] 14 mg [ ] 7 mg Chest wall daily Physician Signature
3 Allergies Myocardial Infarcti Order Set Date/Time Medicati Profile : All Medicatis must be reviewed prior to discharge and circled es or o. [ ] Aspirin Chew 324mg admissi [ ] Aspirin mg po daily ACE1 / ARB: Beta Blocker: itrates: [ ] Lovenox 1 mg/kg Subcutaneous q hours. *Adjust for age or renal insufficiency IV MEDICATIOS [ ] Heparin bolus5000 units IV and start drip at 1000 units / hr and follow omogram. [ ] Heparin for patient less than 70 kg modify per MD. [ ] itroglycerine drip start at 10 mc /min and titrate for relief chest pain, maintain Sys BP mm Hg [ ] Morphine Sulfate 2mg IV q 5 minutes for chest pain not relieved with itroglycerin. [ ] Metoprolol 5mg IV q 5 min x 3 doses provided sys BP greater 90 mm Hg and HR greater 50 / min [ ] Diuretic IV: [ ] Aggrastat bolus and maintenance drip per protocol using kg. dose chart - normal renal functi [ ] Aggrastat bolus & maintenance drip per protocol using kg. dose chart for impaired renal functi (Creatinine clearance less then 30ml/min) [ ] Integrilin bolus & maintenance drip per protocol, 180mcg/kg bolus followed by 2mcg/kg/min [ ] Integrilin bolus and maintenance drip per protocol, 180mcg/kg bolus followed by 1mcg/kg/min infusi. *If serum Creatinine is 2mg/dl to 4mg/dl [ ] Retavase 10 units bolus over 2 min repeat 10 unit bolus in 30 minutes
4 Date & Time GEERAL ORDERS Date & Time MEDICATIO ORDERS Allergies
5 Orders Date Time 1. patient all medicatis circled es and enter Medicati Card 2. patient to: [ ] Home [ ] Home Health [ ] Hospice [ ] Other: 3. Instructis: Activity: 4. Instructis: Diet: [ ] Low sodium diet [ ] If diabetic, Calorie ADA Diet [ ] Other: 5. Instructis: [ ] Weigh yourself daily and report gains of lbs [ ] Restrict fluids 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 11. [ ] Fax Orders & 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 Physician Signature
Pediatric Order Set 0 through 16 yrs age Addressograph Stamp
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:
Physician Orders ADULT: Acute MI/Acute Coronary Syndrome Adult Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: Acute MI/Acute Coronary Syndrome Adult Phase, When to Initiate: Acute MI/Acute Coronary Syndrome Adlt Phase Non Categorized
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
Admit date (YYYY/MM/DD): Cardiologist On-Call: Diagnosis: Lab Tests. CBC, Electrolytes, Urea, Creatinine, Glucose, INR, PTT, Urinalysis
of nurse 1. Admit under ward Attending Physician: Dr. Admit date (YYYY/MM/DD): Cardiologist On-Call: Diagnosis: Lab Tests 2. On admission (if not already performed in Emergency Department or in Coronary
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
DOWNTIME Physician Order CARD CHF Heart Failure
DOWNTIME Physician Clinical Category ADT/Comm unication Patient Status ASC Extended Recovery Observation Services Inpatient Admission CCU Admit as Inpatient History and Physical by House Physician Vital
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:
Physician Orders ADULT: PCI Post Procedure Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: PCI Post Procedure Phase, When to Initiate: Initiate Powerplan Phase Phase: Post Cath/PCI Hydration Protocol Phase,
Physician Orders ADULT: Atrial Fib/Flutter Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: Atrial Fib/Flutter Phase, When to Initiate: Atrial Fib/Flutter Phase Non Categorized Problem: Atrial fibrillation Problem:
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
Available at ALL facilities Non Categorized SUB ED Chest Pain: STEMI Protocol(SUB)* SUB ED Chest Pain: STEMI Protocol Lab Orders(SUB)* ED Rainbow Tubes(SUB)* ***Reminder: Order ED Rainbow Tubes (SUB) as
* * FORM REV. 02/2019 Page 1 of 4. TNKASE (tenecteplase) / ACUTE STEMI ORDERS SCHEDULED MEDICATIONS:
1. Is this a CMS inpatient only procedure? Yes, admit as inpatient, proceed to # 3 No, proceed to # 2 2. Do you expect that the patient s condition will require a hospital stay that will cross two midnights
HOW TO USE THE CLINICAL PATHWAY
1. 2. 3. 4. INCLUSION CRITERIA Primary admitting diagnosis is Congestive Heart Failure as defined by New York Heart Association. EXCLUSION CRITERIA Patients less than 19 years of age. HOW TO USE THE This
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.
Chest Pain Acute Coronary Syndrome Version 4 4/10/17 This order set is designed to be used with an admission set or for a patient already admitted
Patient Name: Diagnosis: Allergies with reaction type: Chest Pain Acute Coronary Syndrome Version 4 4/10/17 This order set is designed to be used with an admission set or for a patient already admitted
OBSERVATION UNIT ASTHMA PATHWAY OUTLINE Westmoreland Hospital PAGE 1 OF 5
PAGE 1 OF 5 Exclusion Criteria: (Reason to admit to hospital) A. New EKG changes except sinus tachycardia B. Respiratory Rate > 40 C. Signs/symptoms of Heart Failure D. Impending respiratory failure or
IR Central Venous Access [ ] Pre Procedure
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CONGESTIVE HEART FAILURE CLINICAL PATHWAY ACUTE STAGE GREY BRUCE HEALTH SERVICES Lion's Head Markdale Meaford Owen Sound Southampton Tobermory Wiarton 1. 2. 3. 4. INCLUSION CRITERIA EXCLUSION CRITERIA
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Orthopedic Admission Hip Fracture Version 2 1/25/2017
Patient Name: Initial each page and Sign/Date/Time last page Diagnosis: Allergies with reaction type: Orthopedic Admission Hip Fracture Version 2 1/25/2017 Patient Placement Patient Status If the physician
DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available at: BMC-B BMC-D BMC-N BMC-S Vital Signs Vital Signs Q4H (DEF)* Q2H Q1H Vital Signs Orthostatic Activity Activity Bedrest, for 12 hours then Up ad lib (DEF)* Bedrest, for 24
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 Available at: BMC-B BMC-D BMC-N BMC-S Vital Signs Vital Signs Q4H (DEF)* Q2H Q1H Vital Signs Orthostatic Activity Activity Bedrest, for 12 hours then Up ad lib (DEF)* Bedrest, for 24
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Non Categorized SUB Sub Phase (SUB)* Non Categorized Quality Measures STK Diet ED NPO Until Bedside Swallow Screen passed Nursing Orders Activate Code Stroke Vital Signs Q15MINS Int
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Cardiac Stress Test [3041300006] Procedures Cardiac Studies Stress Tests (Single Response) ( ) EKG Only Exercise Stress Test - Treadmill Do Not Order if: Baseline ST segment abnormalities on EKG (LBBB,
HOW TO USE THE CLINICAL PATHWAY
ACUTE CORONARY SYNDROMES CLINICAL PATHWAY ACUTE STAGE GREY BRUCE HEALTH SERVICES Lion's Head Markdale Meaford Owen Sound Southampton Tobermory Wiarton PATIENT ID INCLUSION CRITERIA Patients who present
IDPH ESF-8 Plan: Pediatric and Neonatal Surge Annex Sample Pediatric Admission Orders 2015
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Level 1: Acute CHF with Hypotension (SBP < 90 torr)
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Physician Orders ADULT: Sickle Cell Inpatient Plan
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ADMIT DIABETIC KETOACIDOSIS (DKA) PLAN - Phase: Begin Immediately/Emergency Center
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HOW TO USE THE CLINICAL PATHWAY
CONGESTIVE HEART FAILURE CLINICAL PATHWAY ACUTE STAGE HANOVER AND DISTRICT HOSPITAL 1. 2. 3. 4. INCLUSION CRITERIA Primary admitting diagnosis is Congestive Heart Failure as defined by New York Heart Association.
Atrial Fibrillation Version 2 11/4/15 This order set must be used with an admission order set if patient not already admitted.
Patient Name: Diagnosis: Allergies with reaction type: Atrial Fibrillation Version 2 11/4/15 This order set must be used with an admission order set if patient not already admitted. Telemetry Medical Telemetry:
(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
PEDIATRIC SPINE SURGERY POST-OP PLAN - Phase:.
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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:
Bariatric Surgery Post Op Day Version 2 Approved 11/13/2017
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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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Physician Orders ADULT: Renal Transplant Admit Plan
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ADULT TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR) TELEMETRY BED TRANSFER ORDERS 1 of 4
TELEMETRY BED TRANSFER 1 of 4 9 Actual 9 Estimated Patient ID Area Weight kg 9 Actual 9 Estimated Height cm ALLERGIES: REFER TO ALLERGY PROFILE/ POWERCHART Transfer to: 10 South Attending Physician: Diagnosis:
SN Visit Note. Vital Signs. Blood Sugar. Oxygen. Allergies. Pain Assessment. Visit Date: Episode Date: Patient Name: Patient ID:
Patient Name: Patient ID: Visit Date: Episode Date: SN Visit Note Vital Signs Not ed Temperature: Pulse Apical: Reg Irreg Resp: / min Pulse Radial: Reg Irreg B/P (L) B/P (R) Sitting: / Sitting: / Standing:
Physician Orders ADULT: Asthma and Bronchitis Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase, Phase: Asthma and Bronchitis Phase, When to Initiate: Asthma and Bronchitis Phase Non Categorized Problem: Asthma Problem:
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ST. DOMINIC-JACKSON MEMORIAL HOSPITAL JACKSON, MISSISSIPPI
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Diagnosis: Allergies with reaction type:
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Sample. Affix patient label within this box.
Instructions for completing orders Complete pages 1-3 for General Inpatient Orders. All pathway compatible orders (indicated by ) within the General Inpatient Orders will be followed automatically. Optional
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
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. (Patient Sticker) CDH 208-203 Approved 2/18 - Page 1 of 5 Patient: DOB: Gender: Patient Phone #: Height: Weight: Diagnosis: ICD-10 Code: Treatment Start Date: Provider Facility Name: Ordering Provider:
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Routine, Every 2 hours, Starting today, If temperature greater than 38.5 C initiate Evaluation for Possible Sepsis Physician Order #829
Height Weight Allergies General Vital Signs [X] Frequent vital signs Indication: Q15 minutes x (# of occurrences): 4 Q30 minutes x (# of occurrences): 4 Q1 hour x (# of occurrences): Q2 hours x (# of occurrences):
Physician Orders PEDIATRIC: LEB Kidney Transplant Post Op Plan
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Patient: Becky Smith DOB: 01/26/XXXX Age: 5 y/o Attending: Dr. D. Miles Allergies: NKA MR#: 203. Patient Chart #203 Becky Smith
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Exhibit EP16.h University of Virginia Medical Center Clinical Decision Tool
TITLE: Emergency Management for Suspicion of Cardiac Event PURPOSE: Increasingly, patients have multiple morbidities and are at risk of adverse events related or unrelated to the condition for which they
EFFECTIVE DATE: 01/2007 REVISED: 07/2008, 6/11, 3/12, 8/12, 1/15. Purpose:
1 TITLE/DESCRIPTION: DEPARTMENT: PERSONNEL: Rapid Response Team (RRT) Patient Care Services RN s and RT s EFFECTIVE DATE: 01/2007 REVISED: 07/2008, 6/11, 3/12, 8/12, 1/15 Purpose: A group of select health
DISCUSSION QUESTION - 1
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A UMC Health System Performance Improvement Initiative for use in all units where cardiac/surgical patients are admitted.
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Sample. Affix patient label within this box.
Instructions for completing orders: Determine PRAM Clinical Score as per the Alberta Acute Childhood Asthma Pathway for Emergent/Urgent Care and select orders based on PRAM Score. Custom orders can be
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
URN: Family name: Given name(s): Address: Initial Signature Print Name Role
Do Not Write in this binding margin v5.00-02/2012 Mat. No.: 10206019 SW030b The State of Queensland (Queensland Health) 2012 Contact CIM@health.qld.gov.au ÌSW030bIÎ Facility: s Never Replace Clinical Judgement
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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
DAYTON CHILDREN S HOSPITAL CLINICAL PRACTICE GUIDELINES
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