Physician Order Sets



Please Use Ball Point Pen! PHYSICIANS MUST SIGN, Date and Time ALL ORDERS Please Use Ball Point Pen!

|DATE/TIME |CHK'D BY |PHYSICIAN'S ORDER SHEET |

| | |Psychiatric Treatment Order Set Emergency Department |

| | |Order Set No. 10462 |

| | |Allergies: Reactions: |

| | |Allergies: Reactions: |

| | | Admitting M.D.:/DO/DDS |

| | |Attending M.D.:/DO/DDS |

| | |Referring M.D.:/DO/DDS |

| | | |

| | |1. Emergency Detention due to potential danger of harm to self and/or others |

| | | ( Yellow gown and secure belongings |

| | | ( UDS |

| | | ( Home medication reconciliation |

| | | ( Safe tray |

| | | ( Scan transfer authorization form |

| | | ( Sitter with constant observation |

| | | ( Alcohol, serum |

| | | ( Breath alcohol |

| | | ( Fingerstick glucose Q12 (if diabetic) |

| | | ( Consult Crisis response team |

| | |2. Vitals q 12 hours |

| | |3. Psychosocial assessment per nursing q 12 hours |

| | |4. Call physician IF |

| | | Temp > 100.5 F or < 96.0 F |

| | | Systolic BP > 180mmHg or < 90mmHg |

| | | Diastolic BP > 100mmHg or < 40mmHg |

| | | HR > 110bpm or < 50bpm |

| | | RR > 24 or < 8 per minute or |

| | | SpO2 < 90%. |

| | | |

| | |Precautions |

| | | ( Suicide |

| | | ( Assaultive |

| | | ( Seizure |

| | | ( Elopement |

| | | ( Fall Risk |

| | | ( Other: |

| | | |

| | |Page1 of 4 |

| | |New: June 2017 Physician’s Signature |

| |

|PROHIBITED ABBREVIATIONS |

|PROHIBITED: INSTEAD WRITE |PROHIBITED: INSTEAD WRITE |

|MS, MgSO4 magnesium sulfate |Q.D. daily |

|MS, MSO4 morphine sulfate |QOD every other day |

|U units |.5 mg 0.5 mg – always use zero before decimal |

|IU international units |5.0 mg 5 mg – never use trailing zeroes |

Revised: 4/2014

PHYSICIAN'S ORDER SHEET

THE PHARMACY IS AUTHORIZED TO DISPENSE DRUGS FOR ADMINISTRATION OF ANOTHER GENERICALLY EQUIVALENT BRAND, IDENTICAL IN STRENGTH, DOSAGE FORM, AND CONTENT OF ACTIVE THERAPEUTIC INGREDIENT(S).

*PO2300*

PO2300

Physician Orders

Patient Identification

Please Use Ball Point Pen! PHYSICIANS MUST SIGN, Date and Time ALL ORDERS Please Use Ball Point Pen!

|DATE/TIME |CHK'D BY |PHYSICIAN'S ORDER SHEET |

| | |Psychiatric Treatment Order Set Emergency Department |

| | |Order Set No. 10462 |

| | |Allergies: Reactions: |

| | |Allergies: Reactions: |

| | | |

| | |Diet |

| | | ( Regular diet |

| | | ( Low sodium 2gm diet |

| | | ( Diabetic 2000kcal diet |

| | | |

| | |Medications |

| | | ( Nicotine Patch 14mg patch topical daily for ≤ 20 cigarettes/day |

| | | OR |

| | | ( Nicotine Patch 20mg patch topical daily for > 20 cigarettes/day |

| | | ( Acetaminophen 650mg po q4 hours PRN for pain level 0-4, Max APAP 3g/24hrs |

| | | ( Ibuprofen 400mg po q4 hours PRn for pain level 0-4 |

| | | ( Trazodone 50mg po qhs PRN insomnia; May repeat x1 in 1 hour if not effective for sleep |

| | | |

| | |Consider restarting home medications for chronic medical condition if no contraindications.   |

| | | |

| | |If BP 160 mmHg |

| | | or Diastolic BP > 95 mmHg |

| | | |

| | |Mild to Moderate Agitation |

| | |(For PRN use in those patients experiencing mild to moderate agitation or dangerous |

| | |Behavior, consenting to oral medications.) |

| | |Check only one regime |

| | | ( Haloperidol 5mg PO Q4 hrs PRN agitation |

| | | ( Quetiapine 50mg PO Q2 hrs PRN agitation (Geripsych neurocognitive disorder) |

| | | ( Risperidone disintegrating tab 2mg PO q12 hours PRN agitation |

| | | ( Olanzapine disintegrating tab 10mg PO q12 hours PRN agitation |

| | |With optional addition of: |

| | | ( Lorazepam 2mg PO q4 hours PRN agitation |

| | | Page|

| | |2 of 4 |

| | |New: June 2017 Physician’s Signature |

| |

|PROHIBITED ABBREVIATIONS |

|PROHIBITED: INSTEAD WRITE |PROHIBITED: INSTEAD WRITE |

|MS, MgSO4 magnesium sulfate |Q.D. daily |

|MS, MSO4 morphine sulfate |QOD every other day |

|U units |.5 mg 0.5 mg – always use zero before decimal |

|IU international units |5.0 mg 5 mg – never use trailing zeroes |

Revised: 4/2014

PHYSICIAN'S ORDER SHEET

THE PHARMACY IS AUTHORIZED TO DISPENSE DRUGS FOR ADMINISTRATION OF ANOTHER GENERICALLY EQUIVALENT BRAND, IDENTICAL IN STRENGTH, DOSAGE FORM, AND CONTENT OF ACTIVE THERAPEUTIC INGREDIENT(S).

*PO2300*

PO2300

Physician Orders

Patient Identification

Please Use Ball Point Pen! PHYSICIANS MUST SIGN, Date and Time ALL ORDERS Please Use Ball Point Pen!

|DATE/TIME |CHK'D BY |PHYSICIAN'S ORDER SHEET |

| | |Psychiatric Treatment Order Set Emergency Department |

| | |Order Set No. 10462 |

| | |Allergies: Reactions: |

| | |Allergies: Reactions: |

| | | |

| | |Extreme Agitation or Dangerous Behavior |

| | |(for PRN use in those patients experiencing moderate to extreme agitation or |

| | | dangerous behavior and who likely lack capacity to consent to treatment.) |

| | | ( Haloperidol 5mg PLUS Lorazepam 2mg PLUS Diphenhydramine 25mg IM every |

| | | 2 hours PRN agitation |

| | | |

| | |Extreme Agitation or Dangerous Behavior (Cont.) |

| | | ( Ziprasidone 20mg IM PLUS Lorazepam 2mg IM every 12 hours |

| | | (Dose related QTc prolongation and risk of cardiac arrhythmias with Ziprasidone) |

| | | ( Olanzapine 10mg IM q 8 hours PRN agitation |

| | |Alternative for extreme combative/violent behavior: |

| | | ( Ketamine 4mg per kg IM WEIGHT: |

| | | (Monitor bp and O2 status. In most cases, only effective for initial control.) |

| | | |

| | |Mood Stabilization (may use alone or in combination with any of those below) |

| | |( Divalproex Sodium 1000mg PO at completion of physical and mental assessment. |

| | | (Contraindicated in severe hepatic impairment: Child-Pugh Class C) |

| | | (Caution in women of childbearing age who may be or become pregnant.) |

| | | |

| | |Mood Stabilization and/or Treatment of Psychosis (choose only one) |

| | |( Lurasidone 40mg PO dail7 |

| | | (Consider use in women of child bearing age who may be or become pregnant.) |

| | |( Risperdone 1mg PO BID |

| | | OR |

| | |( Risperidone 0.5 PO BID (for patients with severe hepatic impairment) |

| | | |

| | |( Haloperidol 5mg PO BID (only indicated for psychosis) |

| | | |

| | | Page 3 of 4 |

| | |New: June 2017 Physician’s Signature |

| |

|PROHIBITED ABBREVIATIONS |

|PROHIBITED: INSTEAD WRITE |PROHIBITED: INSTEAD WRITE |

|MS, MgSO4 magnesium sulfate |Q.D. daily |

|MS, MSO4 morphine sulfate |QOD every other day |

|U units |.5 mg 0.5 mg – always use zero before decimal |

|IU international units |5.0 mg 5 mg – never use trailing zeroes |

Revised: 4/2014

PHYSICIAN'S ORDER SHEET

THE PHARMACY IS AUTHORIZED TO DISPENSE DRUGS FOR ADMINISTRATION OF ANOTHER GENERICALLY EQUIVALENT BRAND, IDENTICAL IN STRENGTH, DOSAGE FORM, AND CONTENT OF ACTIVE THERAPEUTIC INGREDIENT(S).

*PO2300*

PO2300

Physician Orders

Patient Identification

Please Use Ball Point Pen! PHYSICIANS MUST SIGN, Date and Time ALL ORDERS Please Use Ball Point Pen!

|DATE/TIME |CHK'D BY |PHYSICIAN'S ORDER SHEET |

| | |Psychiatric Treatment Order Set Emergency Department |

| | |Order Set No. 10462 |

| | |Allergies: Reactions: |

| | |Allergies: Reactions: |

| | | |

| | |For prevention of extrapyramidal side effects and to promote mild sedation |

| | |( Diphenhydramine 50mg PO BID |

| | | OR |

| | |( Benztropine 1mg PO BID |

| | | |

| | |For geriatric agitation in context of major neurocognitive disorder: |

| | |( Quetiapine 50mg PO BID |

| | | AND |

| | |( Quetiapine 200mg PO at HS (Hold if sedated) |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | Page 4 of 4 |

| | |New: June 2017 Physician’s Signature |

| |

|PROHIBITED ABBREVIATIONS |

|PROHIBITED: INSTEAD WRITE |PROHIBITED: INSTEAD WRITE |

|MS, MgSO4 magnesium sulfate |Q.D. daily |

|MS, MSO4 morphine sulfate |QOD every other day |

|U units |.5 mg 0.5 mg – always use zero before decimal |

|IU international units |5.0 mg 5 mg – never use trailing zeroes |

Revised: 4/2014

PHYSICIAN'S ORDER SHEET

THE PHARMACY IS AUTHORIZED TO DISPENSE DRUGS FOR ADMINISTRATION OF ANOTHER GENERICALLY EQUIVALENT BRAND, IDENTICAL IN STRENGTH, DOSAGE FORM, AND CONTENT OF ACTIVE THERAPEUTIC INGREDIENT(S).

*PO2300*

PO2300

Physician Orders

Patient Identification

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download