ACCOUNT NO. MED. REC. NO. NAME BIRTHDATE ALL ORDERS MUST BE MARKED IN INK WITH A CHECKMARK ( ) TO BE ACTIVE.

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Steven Simmons
6 years ago
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1 PO7071 *PO7071* Page 1 of 5 Weight: kg Height: cm Allergies: Diagnosis Code: Treatment Start Date: Patient to follow up with provider on date: **This plan will expire after 365 days at which time a new order will need to be placed** GUIDELINES FOR PRESCRIBING: 1. Send FACE SHEET and H&P or most recent chart note. 2. Please specify base fluid, additives, total volume and rate. LABS COMPLETED- ADDITIONAL LABS: CMP, routine, ONCEevery (visit)(days)(weeks)(months) Circle One CBC with differential, routine, ONCEevery (visit)(days)(weeks)(months) Circle One Urine Dipstick, Ketones, ONCE every (visit)(days)(weeks)(months) Circle One

2 Page 2 of 5 MEDICATION: BAG 1: Base: (must check one) D5LR Lactated Ringers D5/0.45 Normal Saline (align box) NS 0.9% NORMAL SALINE Additives: Folic acid 1 mg Multivitamin (adult, with vitamin K) 10 ml (Note: infuse at least over 2 hours) Potassium chloride meq/l rate is 10 meq/hr. Max dose is 40 meq in 1 Liter Total volume: (must check one) 250 ml IV, ONCE 500 ml IV, ONCE 1000 ml IV, ONCE ml IV, ONCE Rate: (must check one) IF NO ADDATIVES 250 ml/hr 500 ml/hr 1000 ml/hr 2000 ml/hr ml/hr Interval: (must check one) ONCE Every visit Repeat ONCE DAILY every days X DOSES Repeat once every weeks X DOSES

3 BAG 2:ADDITIONAL HYDRATION Base: (must check one) D5LR Lactated Ringers D5/0.45 Normal Saline NS0.9% NORMAL SALINE Total volume: (must check one) 250 ml IV, ONCE 500 ml IV, ONCE 1000 ml IV, ONCE ml IV, ONCE Rate: (must check one) 250 ml/hr 500 ml/hr 1000 ml/hr 2000 ml/hr ml/hr Page 3 of 5 Interval: (must check one) ONCE EVERY VISIT WITH BAG 1 AS NEEDED MEDICATIONS: Anti Emetics Metoclopramide (REGLAN) 10 mg/2ml IV push, AS NEEDED, x 1 dose for nausea/vomiting Ondansetron (ZOFRAN) 4 mg/2ml IV push, AS NEEDED, x 1 dose for nausea/vomiting Promethazine (PHENERGAN) 12.5 mg in NaCl 0.9% ml slow IV push, AS NEEDED for nausea/vomiting H2 Blockers Famotidine HCl (Pepcid) 20 mg IV, AS NEEDED, ONCE Cimetidine HCl (Tagamet) 300 mg IV, AS NEEDED, ONCE

4 NURSING ORDERS (TREATMENT PARAMETERS): 1. Nursing communication order, every visit: Notify provider if urine ketones are greater than trace or orthostatic blood pressure changes are greater than 20 mmhg after 3 liters of IV hydration. 2. Nursing communication order, every visit: Manage line per OHSU Vascular Access Flushing Procedure # HC-NSG-236-PRO (Could include flushes with D5W, NS, heparin 10 units/ml, heparin units/ml,or t-pa 2 mg/2ml) 3. Nursing communication order, every visit: Manage central venous catheter per OHSU De-clotting Procedure for Vascular Access Policy # HC-NSG-126-POL 4. Nursing communication order, every visit: Manage site access per OHSU PICC and Central Venous Access Site Assessment and Dressing Changes Policy # HC-NSG-189-POL BY SIGNING BELOW, I REPRESENT THE FOLLOWING: I am responsible for the care of the patient (who is identified at the top of this form); I hold an active, unrestricted license to practice medicine in: Oregon (check box that corresponds with state where you provide care to patient and where you are currently licensed. Specify state if not Oregon); My physician license Number is # (MUST BE COMPLETED TO BE A VALID PRESCRIPTION); and I am acting within my scope of practice and authorized by law to order Infusion of the medication described above for the patient identified on this form. OLC Central Intake Nurse: Page 4 of 5 Ph: (providers only) Fax: Please check the appropriate box for the patient s preferred clinic location: INFUSION CLINIC LOCATIONS Beaverton OHSU Knight Cancer Institute SW Greystone Court Beaverton, OR Phone number: Gresham Legacy Mount Hood campus Medical Office Building 3, Suite SE Stark Gresham, OR Phone number: NW Portland Legacy Good Samaritan campus Medical Office Building 3, Suite NW 22nd Ave. Portland, OR Phone number: Tualatin Legacy Meridian Park campus Medical Office Building 2, Suite SW 65th Ave. Tualatin, OR Phone number:

5 Page 5 of 5 Provider signature: Date/Time: Printed Name: Phone: Fax: Infusion orders located at:

ACCOUNT NO. MED. REC. NO. NAME BIRTHDATE. Patient Identification ALL ORDERS MUST BE MARKED IN INK WITH A CHECKMARK ( ) TO BE ACTIVE.

ACCOUNT NO. MED. REC. NO. NAME BIRTHDATE. Patient Identification ALL ORDERS MUST BE MARKED IN INK WITH A CHECKMARK ( ) TO BE ACTIVE. PO7071 *PO7071* Page 1 of 4 ALL MUST BE MARKED IN INK WITH A CHECKMARK ( ) TO BE ACTIVE. Weight: kg Height: cm Allergies: Treatment Start Date: Date(s) of Transfusion(s): Current Labs: WBC: Hgb/Hct: Platelets: