Physician'S Order Sheet Page 2
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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 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
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