Physician'S Order Sheet
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1
2PHYSICIAN'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
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