Physician'S Order Sheet - Allergy
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1PHYSICIAN'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.
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Check ( )
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Allergy
Each
Pharmacy
Order As
Orders
Transcribed
Physicians Order
Date:
Time:
PATIENT CONTROLLED ANALGESIA (PCA) ORDERS
MORPHINE SULFATE 1 mg / ml INJ.
1.
Mode:
PCA
CONTINUOUS
PCA & CONTINUOUS
COMPLETE 2 THRU 6 ( below )
DOSING GUIDELINES
2.
PCA Dose
= __________ ml. (mg.)
1 ml. (mg.)
3.
Delay Between Injections
= __________ minutes
10 minutes
4.
Basal (Continuous) Rate
= __________ ml. (mg.)/hr
1 ml. (mg.)
5.
One Hour Limit
= __________ ml. (mg.)
7 ml. (mg.)
6.
Initial Loading Bolus
= __________ ml. (mg.)
2-5 ml. (mg.)
FAXED BY/TIME:
TIME NOTED:
Doctor's Signature ____________________________________,MD Date __________
Nurse's Signature / Title___________________________________________________
Military Time > >
√
Check ( )
√
Check ( )
Allergy
Each
Pharmacy
Order As
Orders
Transcribed
Physicians Order
Date:
Time:
7.
Narcan 0.4 mg. ________ 2 amps to be sent to floor.
8.
Morphine Sulfate 50 mg. syringe.
9.
KVO IV must be maintained for duration of PCA Therapy.
10.
Morphine Sulfate Bolus to be given by physician only. Physician to stay
with patient for 15 minutes after each bolus is given.
11.
Monitor respiratory rate, pulse, blood pressure, pain & LCO scores every
30 minutes X 2 hours, then every 4 hours until PCA is discontinued.
12.
Call Dr. _______________________ or H.O. if patient complains of unrelieved
pain, is difficult to arouse, is confused, or respiratory rate drops below
12 per min, or other.
13.
Instruct patient in proper use of PCA pump
14.
Check drug compatibility list or call Pharmacy
FAXED BY/TIME: TIME NOTED:
Doctor's Signature ____________________________________,MD Date __________
Nurse's Signature / Title___________________________________________________
Military Time > >
USE BALL POINT PEN ONLY - PRESS FIRMLY
PART OF THE MEDICAL RECORD
Morphine Sulfate PCA Physicians Order_MEDICAL AFFAIRS
PAGE 1 of 1
8850176 Rev 05/05
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