"Physician's Order Sheet"

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PHYSICIAN'S ORDER SHEET
ALL ORDERS WILL BE FULFILLED UNLESS CROSSED OUT
AFTER EACH ORDER IS PROPERLY CHECKED, FAX ORDER SHEET
TO PHARMACY WHETHER OR NOT ORDERS INVOLVE MEDICATION.
Check ( )
TOTAL (Left or Right) KNEE ARTHROPLASTY - CLINICAL PATHWAY
Check ( )
Each
Pharmacy
Order As
Orders
DAY 1
DRG #209
PAGE 1 of 2
Transcribed
CROSS THROUGH AND INITIAL ORDERS NOT APPLICABLE
DATE:
TIME:
( Military Time )
ADMIT PATIENT TO:
DIAGNOSIS:
ACTIVITY:
1. Bedrest (day of surgery)
2. OOB chair BID (Beginning POD #1)
3. Weight bearing status _______________________________________________________
LABS:
1. CBC in PACU and Q am x 3
2. PT and INR Q am
RADIOLOGY:
A.P. & Lat of
_____LEFT
_____RIGHT knee in PACU
(check one)
DIET: Advance as tolerated Post-Op
MEDICATIONS: (check options or cross out)
Lovenox 30 mg S.Q. B.I.D.
1st Dose TIME:
DATE:
Coumadin __________ mg
1st Dose TIME:
18:00 Hours
DATE:
Antiemetic prn _____________________ (Drug Name) _______________________________
Route, Dose & Timing
Laxative / Stool softener _____________(Drug Name) _______________________________
Route, Dose & Timing
Antibiotics ________________________(Drug Name) _______________________________
Route, Dose & Timing
Route, Dose & Timing
Antibiotics ________________________(Drug Name) _______________________________
Route, Dose & Timing
Route, Dose & Timing
Antibiotics ________________________(Drug Name) _______________________________
Route, Dose & Timing
Route, Dose & Timing
OTHER MEDICATIONS:
FAXED BY/TIME:
TIME NOTED:
Doctor's Signature ____________________________________,MD Date __________
Military Time > >
Nurse's Signature / Title___________________________________________________
USE BALL POINT PEN ONLY - PRESS FIRMLY
PART OF THE MEDICAL RECORD
PAGE 1 of 2
8850057 Rev 05/05
Total Knee Replacement Physicians Order_CLINICAL PATHWAYS_MEDICAL AFFAIRS
PHYSICIAN'S ORDER SHEET
ALL ORDERS WILL BE FULFILLED UNLESS CROSSED OUT
AFTER EACH ORDER IS PROPERLY CHECKED, FAX ORDER SHEET
TO PHARMACY WHETHER OR NOT ORDERS INVOLVE MEDICATION.
Check ( )
TOTAL (Left or Right) KNEE ARTHROPLASTY - CLINICAL PATHWAY
Check ( )
Each
Pharmacy
Order As
Orders
DAY 1
DRG #209
PAGE 1 of 2
Transcribed
CROSS THROUGH AND INITIAL ORDERS NOT APPLICABLE
DATE:
TIME:
( Military Time )
ADMIT PATIENT TO:
DIAGNOSIS:
ACTIVITY:
1. Bedrest (day of surgery)
2. OOB chair BID (Beginning POD #1)
3. Weight bearing status _______________________________________________________
LABS:
1. CBC in PACU and Q am x 3
2. PT and INR Q am
RADIOLOGY:
A.P. & Lat of
_____LEFT
_____RIGHT knee in PACU
(check one)
DIET: Advance as tolerated Post-Op
MEDICATIONS: (check options or cross out)
Lovenox 30 mg S.Q. B.I.D.
1st Dose TIME:
DATE:
Coumadin __________ mg
1st Dose TIME:
18:00 Hours
DATE:
Antiemetic prn _____________________ (Drug Name) _______________________________
Route, Dose & Timing
Laxative / Stool softener _____________(Drug Name) _______________________________
Route, Dose & Timing
Antibiotics ________________________(Drug Name) _______________________________
Route, Dose & Timing
Route, Dose & Timing
Antibiotics ________________________(Drug Name) _______________________________
Route, Dose & Timing
Route, Dose & Timing
Antibiotics ________________________(Drug Name) _______________________________
Route, Dose & Timing
Route, Dose & Timing
OTHER MEDICATIONS:
FAXED BY/TIME:
TIME NOTED:
Doctor's Signature ____________________________________,MD Date __________
Military Time > >
Nurse's Signature / Title___________________________________________________
USE BALL POINT PEN ONLY - PRESS FIRMLY
PART OF THE MEDICAL RECORD
PAGE 1 of 2
8850057 Rev 05/05
Total Knee Replacement Physicians Order_CLINICAL PATHWAYS_MEDICAL AFFAIRS
PHYSICIAN'S ORDER SHEET
ALL ORDERS WILL BE FULFILLED UNLESS CROSSED OUT
AFTER EACH ORDER IS PROPERLY CHECKED, FAX ORDER SHEET
TO PHARMACY WHETHER OR NOT ORDERS INVOLVE MEDICATION.
Check ( )
TOTAL (Left or Right) KNEE ARTHROPLASTY - CLINICAL PATHWAY
Check ( )
Each
Pharmacy
Order As
Orders
DAY 1
DRG #209
PAGE 2 of 2
Transcribed
DATE:
TIME:
( Military Time )
PAIN MANAGEMENT: (check options or cross out)
Epidural pain management [See Acute Pain Service (APS) orders for Epidural &
Intrathecal Analgesia] -OR-
__________________ (Drug Name) _______________________ (Route, Dose & Timing)
TREATMENTS: (check options or cross out)
I & O q 8 hours
Encourage coughing and deep breathing q 1 hour while awake
Turn and reposition q 2 hours
Position foot of bed and gatch knee of bed
Ice to operative site
Pneumatic compression device _____ Pleipulse or _____ SCUDS
(check one)
Bilateral long TEDS
Knee Immobilizer to operative knee
Auto-transfusion (transfuse within 4 hours, may repeat x1, then convert to hemovac)
Foley catheter if unable to void within 8 hours Post-Op
Continuous Passive Motion Machine. Set at _____ degrees of flexion, beginning
on _______________ (date) at __________________ (military time).
Incentive Spirometer q 1 hour while awake
IV: ____________ at ________ ml/hr continuously. Convert to saline lock once tolerating PO flu
VITAL SIGNS q 8 hours
PHYSICAL THERAPY consult for ambulation and strengthening exercises, starting POD
#1 and once a day thereafter
OCCUPATIONAL THERAPY consult for ADL's to start POD #1 and once a day thereafter
SOCIAL SERVICE & CASE MANAGEMENT (CM) consults for D/C planning
FAXED BY/TIME:
TIME NOTED:
Doctor's Signature ____________________________________,MD Date __________
Military Time > >
Nurse's Signature / Title___________________________________________________
USE BALL POINT PEN ONLY - PRESS FIRMLY
PART OF THE MEDICAL RECORD
Total Knee Replacement Physicians Order_CLINICAL PATHWAYS_MEDICAL AFFAIRS
PAGE 2 of 2
8850057 Rev 05/05
Page of 2