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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Allergy
Pharmacy
Order As
Orders
Transcribed
PHYSICIAN'S ORDER
Date:
Time:
MEDICATIONS GIVEN DURING ARTERIOGRAM
I. VERSED ____________ mg / IV
II. FENTANYL ____________ mcg / IV
III. OTHER MEDICATIONS GIVEN:
PATIENT STATUS - POST ARTERIOGRAM ORDERS
:
1A. ADMIT (inpatient)
NOTE
MEDICAL JUSTIFICATION MUST BE PROVIDED IN PATIENT CHART (or)
1B. OBSERVE (outpatient) x ____________ hrs & discharge to home at ____________ am / pm
2A. Complete bedrest x ____________ hrs with right / left leg extended, may elevate HOB
30 degrees; may logroll side to side.
2B. Complete bedrest x ____________ hrs with right / left arm extended. DO NOT USE ARM
FOR BP; may sit up.
FAXED BY/TIME:
TIME NOTED:
Doctor's Signature ____________________________________,MD Date __________
Nurse's
Signature / Title__________________________________________ Date __________
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Allergy
Pharmacy
Order As
Orders
Transcribed
Date:
Time:
3. Check arteriogram site for bleeding & distal pulses with vital signs as follows:
q15min x 4; q30min x 2; q 1 hour x 4; then _______________________
4. Resume pre-arteriogram diet now.
5. Encourage patient to drink ________ ml fluids today.
6. Tylenol 2 tabs po q 4 prn for arteriogram site discomfort.
7. Resume all other pre-arteriogram orders.
8. Continue IV of ________ at ________ ml / hour.
9. May d/c IV at ________ .
FAXED BY/TIME: TIME NOTED:
Doctor's Signature ____________________________________,MD Date __________
Nurse's
Signature / Title__________________________________________ Date __________
USE BALL POINT PEN ONLY - PRESS FIRMLY
PART OF THE MEDICAL RECORD
Dilaudid PCA Orders_PHARMACY
PAGE 1 of 1
8850510 Rev 05/05
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