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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