PHYSICIAN ORDER SHEET



PHYSICIAN ORDER SHEET

|Prohibited |Allowed |

|U |Unit |

|IU |International Unit |

|Q.D.; QD; q.d.; qd |Daily |

|Q.O.D.; QOD, q.o.d.; qod |Every other day |

|Trailing zeros (5.0 mg) |No trailing zeros (5 mg) |

|No leading zeros (.5 mg) |Leading zeros (0.5 mg) |

|MS and MSO4 |morphine sulfate |

|Mg and MgSO4 |magnesium sulfate |

|ALLERGIES: |

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|IMPORTANT:ACCORDING TO HOSPITAL POLICY DOSE-RANGE/FREQUENCY RANGE ORDERS ARE NOT ACCEPTABLE |

|DATE/TIME |PATIENT CARE ORDERS |INDICATION (ANTIBIOTICS: INCLUDE SITE &|

|(MM/DD/YY) |(MEDICATIONS, DIET, LABORATORY,X-RAY,ETC.) |SUSPECTED ORGANISM) |

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| I have reviewed the patient’s medications and reconciled them with the transfer orders. |

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|Date:_____________ Time:_____________ Physician’s printed name:___________________________________________ |

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|Physician’s signature:_______________________________________________ |

|REGULATIONS REQUIRE THAT ALL ORDERS CONTAIN A DATE, TIME, SIGNATURE, AND IDENTIFIER (PAGER, PRINTED NAME, ETC.) |

Unless written as “do not substitute” by prescriber, approval is given that all pharmaceuticals ordered by trade name may be dispensed with the generic or therapeutic alternate as defined by the Mercy Fitzgerald Hospital Pharmacy and Therapeutics Committee and the Medical Staff.

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DC403 PICC /Midline orders 5/1/07 wab

PHARMACY STAT LABEL

Doctor’s Pre-Printed Standing orders

Picc/Midline orders: Standing orders

(Picc nurse circle requested orders)

1. Place Picc/Midline per MFH policy.

2. Single, Double, Triple lumen Picc/Midline inserted (circle one)

3. After insertion of new Picc line and x-ray verification of Picc line in SVC or SVC/RA junction, Picc line may be used. If not in SVC, or SVC/RA junction, please notify Picc team.

4. Must use a 10ml syringe or larger for all flushing and IV push medications.

5. Fluid and medications may be delivered continuously, intermittently or IV push. Use only a 10ml syringe or greater.

6. Flush Picc/Midline with 10ml NSS q 12 hours and/or after each intermittent use when not continually running.

7. Call Picc team for any questions regarding Picc/Midline.

8. Dressing to be changed in 24 hours then weekly by Picc nurse. Caps to be changed Q 3 days by floor nurse.

9. If Picc/Midline is 18 gauge or larger, may obtain blood specimens (syringe method only) Pulse flush with 20ml NSS after draw.

10. Blood may be administered through the Picc/Midline if it is an 18 gauge or larger.

11. If Picc team is unable to place Picc line, please consult IR.

12. If Picc line becomes occluded may use Tpa per policy, by Picc team only.

13. May perform any future PICC exchanges that may be needed.

Orders must be signed prior to Picc Placement!

PHYSICIANS SIGNATURE ______________________________________

Date: __________

PRINT NAME __________________________________________________

Time: __________

Patients Sticker

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