Download Western Maryland Health System

WESTERN MARYLAND HEALTH SYSTEM
Physician Orders
REMINDER: ALL MEDICATION ORDERS REQUIRE DOSE, ROUTE, FREQUENCY
DO NOT USE ABBREVIATIONS
Page 1 of 3
DOCTORS ORDERS
GENERAL INTRAOP
CHECK OFF/
INITIALS
Intra Op Procedures
1. Insert Foley:
 French
 Foley
 Coude
 Malecot
 Silicone
2. Sequential Compression Device
 Knee High
3. TEDS
 Thigh High
 Knee High
4. Plexipulses:
 Right Foot
 Left Foot
 Bilateral Feet
5. Remove hair:
 Clippers
6. Prep Skin :
 Isopropyl Alcohol 70%
 Povidone Iodine (Betadine®) 7.5% Scrub
 Povidone Iodine (Betadine®) Solution 10%
®
 Povidone Iodine (Betadine ) 7.5% Scrub-RN/Povidone Iodine (Betadine®) 10 % Solution-MD
 Povidone Iodine (Betadine®) 5% Spray
 DuraPrep®
 Chlorhexidine Gluconate 2% / Isopropyl Alcohol 70% (ChloraPrep®)
 4% Chlorhexidine Gluconate (Hibiclens®/Endure®)
 0.9% Sodium Chloride
 No Prep
 Other: ____________________________________________________________
7. Discontinue Foley as per protocol
Intra Op Medications Pain Control:
 Bupivacaine Hydrochloride (Marcaine®) 0.25% topical as needed for pain
amount _______ time _______________
 Bupivacaine Hydrochloride (Marcaine®) 0.25% with Epinephrine 1:200,000 topical as needed for pain
amount _______ time _______________
 Bupivacaine Hydrochloride (Marcaine®) 0.25% subcutaneous as needed for pain
amount ______ time _______ or from _____________- to _______________
 Bupivacaine Hydrochloride (Marcaine®) 0.25% with Epinephrine 1:200,000 subcutaneous as needed for pain
amount _______ time _______ or from ____________ to ______________
 Bupivacaine Hydrochloride (Marcaine®) 0.5% subcutaneous as needed for pain
amount _______ time ________ or from ___________ to______________
 Bupivacaine Hydrochloride (Marcaine®) 0.5% with Epinephrine 1:200,000 subcutaneous as needed for pain
amount _______ time _________ or from __________to _____________
 Lidocaine (Xylocaine®) 1% subcutaneous as needed for pain
amount ________ time _________ or from ________ to ______________
 Lidocaine (Xylocaine®) 1% with Epinephrine 1:100,000 subcutaneous as needed for pain
amount ________ time _________ or from _________ to_________________
 Lidocaine (Xylocaine®) 1% with Epinephrine 1:200,000 subcutaneous as needed for pain
Amount________ time__________ or from ________to __________________
 Lidocaine (Xylocaine®) 2% subcutaneous as needed for pain
amount ________ time__________or from ____________ to______________________
 Lidocaine (Xylocaine®) 2% with Epinephrine 1:100,000 subcutaneous as needed for pain
amount _________ time___________ or from ______________ to______________________
 Mepivacaine (Carbocaine®) 1% subcutaneous as needed for pain
amount __________ time___________or from ____________ to________________________
 Bupivacaine Hydrochloride (Marcaine®) 0.5% pain pump 400 ml as needed for pain
 Lidocaine (Xylocaine®) 2% with Epinephrine 1:200,000subcutaneous as needed for pain
Time ___________
or From ____________
To _______________
Amount _______
Physician Sig/Date/Time:
Revised: 3/06; 9/06; 6/07; 9/07; 10/07; 10/30/07; 9/08; 4/09; 5/09; 3/10; 9/11;12/12;12/13
Reviewed: 10/09
Form #12.18-010
Western Maryland Health System
Physician Orders
Page 2 of 3
DOCTORS ORDERS
CHECK OFF/
GENERAL INTRAOP
INITIALS
Intra Op Medications: Antibiotics
 50,000 units Bacitracin, 500,000 units Polymyxin B in 0.9% Sodium Chloride
 in 1000mL
 150,000 units Bacitracin, 1,500,000 units Polymyxin B in 0.9% Sodium Chloride 3000mL.
Used for infection control as irrigation: amount
time
or from
to
 Cefoxitin (Mefoxin®) 1 gram
OR
 Cefoxitin (Mefoxin®) 2 grams
In 3000 mL 0.9% Sodium Chloride
Used for infection control as irrigation: amount
time
or from
to
 Cefazolin (Ancef®)1 gram in 1000mL 0.9% Sodium Chloride
Used for infection control as irrigation: amount
time
or from
to
 Cefazolin (Ancef®)1 gram in 1000mL 0.9% Sodium Chloride
Used for infection control to soak mesh
time or from
to
.
 Cefazolin (Ancef®)1 gram
OR
 Cefazolin (Ancef®) 2 grams
AND Heparin 2000 units in 1000 mL 0.9% Sodium Chloride
Used as an anticoagulant and for infection control as irrigation Amount
time
or from
 Bacitracin Ointment
 Povidone Iodine (Betadine®) 10% ointment
Used topically for infection control Amount
time
or from
to
 0.9% Sodium Chloride for infection control as irrigation
Amount
time
or from
to
 Sterile water for infection control as irrigation
Amount________ time_______ or from_______ to ___________
to_____ _
Intra Op Medications – Anti-inflammatory
 Dexamethasone (Decadron®) 4mg/mL subcutaneous as needed as anti-inflammatory
Amount
time
or from
to
 4mg Dexamethasone (Decadron®) and _____mL Bupivacaine Hydrochloride (Marcaine®) 0.5%
subcutaneous as needed for pain and anti-inflammatory
Amount
time
or from
to
Intra Op Medications – Hemostasis
 Microfibrillar Collagen Hemostat (Avitene®) 70 mm by 35 mm by 1mm sheet
 Oxidized regenerated cellulose (Surgicel®) 4” by 8”
 Gelatin absorbable sponge (Gelfoam® ) 50
 Gelatin absorbable sponge (Gelfoam®) compressed 100
®
 Arista AH absorbable topical surgical hemostat
Topical as needed for hemostasis - Amount
time
or from
to
Intraop Medications
 Interceed® 3” by 4”
 Seprafilm® 3” by 5”
Topical as needed for adhesion barrier - Number of pieces______________
time_____________
 Omnipaque 350 mg
as needed for fluoroscopy - Amount
time
or from
to
 Glucagon (Glucagen®) used topically to inhibit gastrointestinal mobility
Amount
time
or from
to
 Methylene Blue Injection 1%
Used to dye lymph nodes - Amount
time
or from
to
 Isosulfan Blue (Lymphazurine® ) 1% Injection
Used to dye lymph nodes - Amount
time
or from
to
Other:
Physician Sig/Date/Time
Revised: 3/06; 9/06; 6/07; 9/07; 10/07; 10/30/07; 9/08; 4/09; 5/09; 3/10; 9/11;12/12;12/13
Reviewed: 10/09
Form #12.18-010
Western Maryland Health System
Physician Orders
Page 3 of 3
DOCTORS ORDERS
CHECK OFF/
GENERAL INTRAOP
INITIALS
Intraop Medications: Anticoagulants
 Heparin 1000 units per mL
mL injected as needed for anticoagulation
 Heparin 100 units per mL
mL injected as needed for anticoagulation
 Heparin 5000 units per mL ______mL in:
15 mL injectable 0.9% Sodium Chloride
1000 mL injectable 0.9% Sodium Chloride
500 mL injectable 0.9% Sodium Chloride
amount injected as needed for anticoagulation
time or from
 Injectable 0.9% Sodium Chloride used to flush catheter
Amount
time
or from
to
Other:
time or from
time or from
to
to
to
Intraop Medications: Lubricants
 E-Z Jelly®
 Surgilube®
 Aquasonic® 100
used topically as lubrication – Amount_________
Blood Products
 Packed RBC's
 Platelets
 Fresh Frozen Plasma
 Number of Units ________
Intraop Labs
 CBC  Type and Crossmatch
 Other__________________
 Hgb/ Hct
ABG
Urinalysis
Intraop Radiology
 Fluoroscopy /portable
VORV per Dr ___________/ _____________________________RN
Physician/Date/Time:
Nurse/Date/Time:
Each page of orders requires physician’s signature, date and time
Only last page requires nurse’s signature, date and time
Original to Patient’s Chart
Revised: 3/06; 9/06; 6/07; 9/07; 10/07; 10/30/07; 9/08; 4/09; 5/09; 3/10; 9/11;12/12;12/13
Reviewed: 10/09
Form #12.18-010