PHYSICIAN ORDER FORM



Saint Luke’s South

Overland Park, KS 66213

Physician Orders

Write Down and Read Back for all Verbal Orders

|DATE |TIME |ANOTHER MEDICATION SIMILAR IN FORM AND ACTION MAY BE DISPENSED PER MEDICAL STAFF POLICY |

| | |Pre Printed Insulin Orders |

| | |Part A – Subcutaneous Insulin Orders |

| | | |

| | |Level of service: |

| | |Outpatient |

| | |Monitored OP (indicate nursing area): Med/Surg Telemetry |

| | |Inpatient (indicate nursing area): Med/Surg Telemetry ICU |

| | |Diet: Nothing by Mouth Clear Liquid Regular ADA _________________ |

| | | Allergies: ________________________ |

| | |General information: |

| | |Notify physician if patient’s status is changed to nothing by mouth, or tube feedings discontinued or started. |

| | |Humalog, rapid acting insulin will be administered immediately prior to meals unless otherwise specified. |

| | |Regular and NPH will be administered 30 minutes prior to meal unless otherwise specified. |

| | |Follow hypoglycemia guidelines from patient care protocol unless otherwise ordered. |

| | | One time order |

| | |Cancel all previous sliding scale insulin orders |

| | |Notify physician if blood glucose is less than _______________or greater than _______________ |

| | |Accucheks |

| | | |

| | |Every 4 hours: 0600 – 1000 – 1400 Every 6 hours: 0600 – 1200 |

| | |1800 – 2200 – 0200 1800 – 2400 |

| | |(Recommended for diet restriction of nothing by mouth, or on continuous sources of enteral nutrition). |

| | | |

| | |AC and HS (Before meals and at Bedtime) (Recommended when eating). |

| | |Other_____________________________________________ |

| | |Before meals or other specified time |

| | |Breakfast |Lunch |Dinner |Bedtime |

| | | Humalog______Units | Humalog _____Units | Humalog _____ Units | Glargine _____ Units |

| | |Regular________Units | |Regular ______Units |(Lantus) |

| | |NPH_________Units |Regular______Units |NPH ________ Units |Levemir ____ Units |

| | |Other________ Units | |Other________ Units |(Detemir) |

| | | | | |NPH ______ Units |

| | | |

| | | |

| | | |

| | |Physician Signature/Date:__________________________________________________ |

|Allergies / Intolerances |DANGEROUS ABBREVIATIONS – DO NOT USE! |Affix Patient Label To ALL Pages |

| |MS, MSO4, MgSO4, q.d. or QD, q.o.d. or | |

| |QOD, U or u, IU | |

| | | |

|Height ______ | | |

|Weight ______ kg gms | | |

| | | |

|Latex Allergy Yes No | | |

|Page 1 of 2 |Never use zero after decimal point (1.0 mg) | |

|SLS-DM-1046 (Rev. 04/23/09) |Always use zero before decimal point (0.5 mg) | |

Saint Luke’s South

Overland Park, KS 66213

Physician Orders

Write Down and Read Back for all Verbal Orders

|DATE |TIME |ANOTHER MEDICATION SIMILAR IN FORM AND ACTION MAY BE DISPENSED PER MEDICAL STAFF POLICY |

| | |Pre Printed Insulin Orders |

| | |Part B – Sliding Scale Insulin Orders |

| | | |

| | |* Sliding scales are for short-term use only. |

| | |Notify physician if patient’s status is changed to nothing by mouth, or diet resumed, tube feeding discontinued or started, or change in IV |

| | |fluids. |

| | |All insulin is administered subcutaneously (preferably in the abdomen) |

| | |Humalog insulin Regular insulin |

| | |Physician guidelines for starting sliding scale Level: |

| | |Start on Level 1 if: (Start here for most patients) |

| | |Pt wt less than 200 lbs or |

| | |Total daily insulin dose less than 60 units |

| | |or |

| | |History of Hypoglycemia |

| | |Start on level 2 if: |

| | |Patient wt greater than 200 lbs |

| | | |

| | |Total daily insulin dose 60-90 units |

| | | |

| | |Start of level 3 if: |

| | |Total daily insulin dose 90-120 units |

| | |Start on level 4 if: |

| | |Total daily insulin dose greater than 120 units |

| | | |

| | |Re-evaluate level by reviewing response |

| | |Continued use of sliding scale should be evaluated daily |

| | | |

| | |Circle Entire Column of Sliding Scale Insulin(SSI) Level Desired |

| | |Blood Glucose |Level 1 |Level 2 |Level 3 |Level 4 |Custom |

| | |Less than70 mg/dl |* |* |* |* |__________Units |

| | |71-100 mg/dl |0 Units |0 Units |0 Units |0 Units |__________Units |

| | |101-150 mg/dl |1 Units |2 Units |3 Units |4 Units |__________Units |

| | |151-200 mg/dl |2 Units |4 Units |6 Units |8 Units |__________Units |

| | |201-250 mg/dl |3 Units |6 Units |9 Units |12 Units |__________Units |

| | |251-300 mg/dl |4 Units |8 Units |12 Units |16 Units |__________Units |

| | |301-350 mg/dl |5 Units |10 Units |15 Units |20 Units |__________Units |

| | |351 mg/dl |6 Units |12 Units |18 Units |24 Units |__________Units |

| | |> 400 mg/dl |Call MD |Call MD |Call MD |Call MD |Call MD |

| | |SSI before meals only unless the following box is checked SSI before meals & bedtime |

| | |If bedtime insulin ( with exception to: Glargine/lantus or Levemir/detemir) is administered, check blood glucose at midnight and 0300 for |

| | |safety. |

| | |If bedtime blood sugar is less then 120 mg/dl and insulin is given, give 15 gram carbohydrate bedtime snack. |

| | |* Follow hypoglycemia guidelines from Patient Care Protocol |

| | | |

| | |Physician Signature/Date:__________________________________________________ |

|Allergies / Intolerances |DANGEROUS ABBREVIATIONS – DO NOT USE! |Affix Patient Label To ALL Pages |

| |MS, MSO4, MgSO4, q.d. or QD, q.o.d. or | |

| |QOD, U or u, IU | |

| | | |

|Height ______ | | |

|Weight ______ kg gms | | |

| | | |

|Latex Allergy Yes No | | |

|Page 2 of 2 |Never use zero after decimal point (1.0 mg) | |

|SLS-DM-1046 (Rev. 04/23/09) |Always use zero before decimal point (0.5 mg) | |

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