Physician Order Sheet Template



|CEDARS-SINAI MEDICAL CENTER |Name: |

|[pic] |MR# |

| |DOB: |

|PHYSICIAN'S ORDER SHEET |Gender |

|BERINERT® vs. Placebo Study (IRB# 21578) | |

|Consent is in front of the chart. | |

| | |

| | |

|NAME OF PHYSICIAN OR DEPARTMENT | |

|Stanley C. Jordan, M.D. | |

|TITLE OF ORDERS: | |

|Berinert® vs Placebo | |

|NOTE: 1. All orders are to be completed, dated, timed, and signed by the physician prior to the | |

|transaction. | |

|2. The physician must circle all items that are to be ordered. | |

|3. Write in blue or black ink only. Use a ballpoint pen and press firmly | |

|4. Orders are to be initialed, signed, dated and timed when they | |

|are transcribed. | |

|ORDERS |

| |

|Weight (prior to start of infusion). |

|Vitals (at start and end of each dose administration) |

|Labs: |

|UA, PT, PTT, D Dimer, Fibrinogen, C1 esterase inhibitor panel, |

|C3 Compliment (prior to dose #8 only) |

|*We may not need these lab orders if pt is scheduled for early pm infusion and pt gets labs from SSB clinic. |

|Premedicate 30 minutes prior to each infusion: |

|Benadryl 50mg po x1 |

|APAP 650mg po x1 |

|Solumedrol 40mg IVP x 1 |

| |

|Berinert® ______ units IVP over ____ minutes x 6 doses (Dose: 20 units/kg; Wt: ___kg) to be given on: |

|Dose 4: __/__/2011 |

|Dose 5: __/__/2011 |

|Dose 6: __/__/2011 |

|Dose 7 : __/__/2011 |

|Dose 8: __/__/2011 |

| |

| |

|PLEASE NOTIFY ASHLEY VO, PHARM.D. (310-993-2717) OR TRANSPLANT FELLOW (pager - 4321), OR STANLEY JORDAN, MD (pager - 3062), OR TRANSPLANT IMMUNOTHERAPY PROGRAM |

|(310-423-2967) WITH QUESTIONS OR PROBLEMS. |

|SIGNATURE OF PHYSICIAN |PHYSICIAN ID NUMBER |DATE |TIME |

|M.D. | | | |

|SIGNATURE OF TRANSCRIBER |INIT |TITLE |DATE |TIME |SIGNATURE OF NURSE (NOTED) |DATE |TIME |

| | | | | |R.N. | | |

Rev 9/20/11 jc

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Allergies:

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