Professional Home I.V.
3781425-41910000Professional Home I.V.Home and Ambulatory Infusion OrdersPatientName:_____________________________DOB:_________________Date:_________________Patient Physical Address:____________________________________________Phone:_____________ ICD10:_______________Diagnosis: ______________________________________________________Height: ______________ Weight: ______________ Allergies:_________________________________Drug/Dose:_____ ____________________________________Route: IV / SQ / IM / EPIDURALTreatment Frequency/ Duration: _______________________End Date__________________________________________Dosage Time: ______________________________________Date/Time of last dose: ______________________________PHIV Start Date: ________________________________Drug/Dose:_________________________________________Route: IV / SQ / IM / EPIDURALTreatment Frequency/ Duration: _______________________Dosage Time: _______________________________________Date/Time of last dose: _______________________________ PHIV Start Date:_________________________________Pain Management Therapy Drug/Dose:__________________*Controlled substance Prescription RequiredRoute: IV / SQ / IM / EPIDURALContinuous Rate: ___________________________________Bolus Dose: _____________ q____________minDuration of Treatment: ______________________________ PHIV Start Date: ________________________________( ) Skilled Nursing: ___________________________________________________________________________________( ) May give antibiotics IM if the IV lines failInstruct Client/Caregiver in:( ) Injectable Med Administration( ) I.V. Line CareI.V. Line Care Orders ( ) Saline/Heplock( ) Hickman/CVP( ) Groshong( ) Port( ) PICC( ) Line Maintenance Pediatric Clients: Specify line and flushing orders:_____________________________________________As per Home IV Therapy Protocol, otherwise specify line orders (flushing and dressing)PULL PICC LINE WHEN THERAPY DONE Y / NCheck appropriate line care order:Date line inserted/PICC Length: _______________________Dressing Change Due: ____________________Tubing Change Due: _____________________Needle Change Due (implanted Caths):_______________Safety/Diet: _________________________________Functional Limitations:_________________________Discharge Plan: _____________________________________Prognosis: _________________________________________Standing Lab Orders( ) BMP ( ) CBC( ) CMP( ) CBC WITH DIFF( ) CRP( ) ESR( ) SCr ( ) Vanco Trough _________( ) ____________________________________________Please send results to Professional Home I.V. fax 907-260-7405And FOLLOW UP PCP________________________________IV Line flush order for blood draws and routine maintenance (PICC, Groshong, Mediport, Hickman/Broviac, Subclavian) Per protocol.( ) Normal Saline 10ml Syringe Disp: #________Sig: USE AS DIRECTED PER LINE CARE ORDERRefill: 1 / 2 / 3 / 4 /PRN( ) Heparin 10Units/ml 5ml Syringe Disp: #________Sig: USE AS DIRECTED PER LINE CARE ORDERRefill: 1 / 2 / 3 / 4 /PRN( ) Cathflow 2mg Disp: #_________Dilute and instill 2ml into the occluded catheter and follow manufactures’ directions.Refill: 1 / 2 / 3 / 4 /PRN( ) CADD Ambulatory Pump ( ) IV Start Kit( ) Elastomeric Infusion Device ( ) CADD Tubing( ) Rate Flow Tubing ( ) Alcohol Swabs/Chloro-prep ( ) Central/Picc Dressing Kit ( ) Surgilast( ) Peripheral Dressing Kit ( ) Other supplies______________ ______________________________________________________Telephone/Verbal Orders: Rec’d By:_______________________Physician’s Signature:______________________________Date:___________ Time___________DEA___________________________Phone__________________NPI_________________________________Address___________________________________________________________________________________________________________________________________________________________ ................
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