Download Outpatient OB [30400732] General Labs

Outpatient OB
[30400732]
Height_____________________
Weight_____________________
Allergies____________________
General
Level of Care (Single Response)
Diagnosis: _________________________(Required)
Monitor for: _________________________(Required)
Notify provider when: _____________________(Required)
Level of Care: _________________________(Required)
Details
Diagnosis: _________________________(Required)
( ) Refer to Observation
( ) Outpatient
Diet/Nutrition
[ ] Diet General
Diet effective now, Starting today
Select/Nonselect: _______________________(Required)
Patient Age:
Additional Modifiers:
Viscosity/Liquids:
Texture:
Fluid Restriction / day:
Supplement:
Diet Comments:
Diet effective now, Starting today
Diet: _______________________(Required)
Additional Modifiers:
Diet Comments:
Diet effective now, Starting today
NPO Except:
Diet Comments:
[ ] Diet Liquid
[ ] Diet NPO
Nursing Assessments
[ ] Fetal non stress test
[X] Initiate OB nursing site specific protocol for labor and
delivery triage
Routine, Once, Starting today
Indication: _______________________(Required)
Routine, Until discontinued, Starting today
Labs
SAH, SCH, SFH, SJMC IP OB Labs
[ ] Pregnancy induced hypertension
[ ] Basic metabolic panel
[ ] CBC and differential
Once, Starting today
Once, Starting today
Once, Starting today
PROVIDER INITIALS: __________
PATIENT INFORMATION
Page 1 of 4
Outpatient OB [30400732]
PHYSICIAN ORDERS
[ ] Amniotic fluid protein test
[ ] Urinalysis with culture, if indicated
[ ] Protein, urine, timed
[ ] Drug screen, urine, OB panel
[ ] Opiates confirmation, urine
[ ] Genital (non-GC) culture and gram stain
[ ] C. trachomatis / N. gonorrhoeae, DNA probe
Once, Starting today
If suspected ruptured membranes, collect specimen and
send to lab for amniotic fluid protein test.
Once, Starting today
Once, Starting today
Timed total protein -12 hour or a 24 hour total protein urine
collection and test.
Once, Starting today
Once, Starting today For 1 Occurrences
Once, Starting today
Specimen Source: _______________________(Required)
Once, Starting today
Highline and Harrison IP OP OB Labs
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Pregnancy induced hypertension
Basic metabolic panel
CBC and differential
Urinalysis with culture, if indicated
Protein, urine, timed
Once, Starting today
Once, Starting today
Once, Starting today
Once, Starting today
Once, Starting today
Timed total protein -12 hour or a 24 hour total protein urine
collection and test.
Once, Starting today
Once, Starting today For 1 Occurrences
[ ] Drug screen, urine, OB panel
[ ] Opiates confirmation, urine
Imaging
OB Diagnostic Imaging
[ ] Ultrasound OB 14 + weeks single or first gestation
[ ] Ultrasound OB 14 + weeks each additional gestation
[ ] Ultrasound fetal biophysical profile without non stress
testing
Routine, 1 time imaging, Starting today For 1
Reason for exam: _______________________(Required)
Is the patient pregnant? Yes
Number of fetuses:
Routine, 1 time imaging, Starting today For 1
Reason for exam: _______________________(Required)
Is the patient pregnant? Yes
Number of fetuses:
Routine, 1 time imaging, Starting today For 1
Reason for Exam: _______________________(Required)
Is the patient pregnant? Yes
Transport Mode: Bed
Transport Mode: Department
IV Fluids
IV Fluids
[ ] Saline Lock Panel
[ ] Saline lock IV
"And" Linked Panel
Routine, Once, Starting today For 1 Occurrences, Flush
peripheral lines every shift.
Discontinue prior to discharge.
PROVIDER INITIALS: __________
PATIENT INFORMATION
Page 2 of 4
Outpatient OB [30400732]
PHYSICIAN ORDERS
[ ] sodium chloride 0.9 % syringe
[ ] Insert peripheral IV
[ ] Lacated Ringers bolus then Lactated Ringers infusion
panel
[ ] lactated ringers (LR) IV bolus
[ ] lactated ringers infusion
10 mL, IntraVENous, Every 8 hours
Flush peripheral lines every shift.
Discontinue prior to discharge.
Routine
Routine, Continuous, Starting today, Start IV line
"Followed by" Linked Panel
500 mL, IntraVENous, for 30 Minutes, Once, For 1
Doses, Routine
125 mL/hr, IntraVENous, Continuous
Discontinue IV when infusion completed.
Routine
Medications
Labor Medications
[ ] terbutaline (BRETHINE) injection
0.25 mg, SubCutaneous, Once as needed, For premature
contractions, For 1 Doses, Routine
0.25 mg, SubCutaneous, Every 20 min PRN, premature
contractions, For 3 Doses
Hold if pulse greater than 110.
Routine
10 mg, Oral, Once, For 1 Doses, Routine
[ ] terbutaline (BRETHINE) injection
[ ] NIFEdipine (PROCARDIA) capsule
Sedative
[ ] zolpidem (AMBIEN) tablet
5 mg, Oral, Nightly PRN, sleep, For 1 Doses, Routine
Misoprostol for Induction
[ ] misoprostol (CYTOTEC) tablet
50 mcg, Oral, Every 3 hours, For 3 Doses
For outpatient induction/cervical ripening
Routine
25 mcg, Oral, Every 3 hours, For 3 Doses
For outpatient induction/cervical ripening
Routine
[ ] misoprostol (CYTOTEC) tablet
Oxytocin - Induction - Start at 1 milli-units/minute
[ ] oxytocin in dextrose 5% 15 unit/250 mL IVPB
1 milli-units/min, IntraVENous, As needed, Labor and
Delivery
PRN Comment: _______________________(Required)
Increase by 1 milli-units/min every 30-40 minutes to a
maximum dose of 20 milli-units/min.
Routine
PROVIDER INITIALS: __________
PATIENT INFORMATION
Page 3 of 4
Outpatient OB [30400732]
PHYSICIAN ORDERS
[ ] oxytocin in dextrose 5% 15 unit/250 mL IVPB
[ ] oxytocin in dextrose 5% 15 unit/250 mL IVPB
1 milli-units/min, IntraVENous, As needed, Labor and
Delivery
PRN Comment: _______________________(Required)
If no contractions by 4 milli-units/min increase rate by 2
milli-units/min every 30-40 minutes.
Routine
1 milli-units/min, IntraVENous, As needed, Labor and
Delivery
PRN Comment: _______________________(Required)
If no contractions by 4 milli-units/min increase rate by 3
milli-units/min every 30-40 minutes.
Routine
Oxytocin - Induction - Start at 2 milli-units/minute
[ ] oxytocin in dextrose 5% 15 unit/250 mL IVPB
[ ] oxytocin in dextrose 5% 15 unit/250 mL IVPB
[ ] oxytocin in dextrose 5% 15 unit/250 mL IVPB
2 milli-units/min, IntraVENous, As needed, Labor and
Delivery
PRN Comment: _______________________(Required)
Increase by 1 milliunit/minute every 30-40 minutes to a
maximum dose of 20 milliunit/minute.
Routine
2 milli-units/min, IntraVENous, As needed, Labor and
Delivery
PRN Comment: _______________________(Required)
If no contractions by 4 milliunits/minute increase rate by 2
milliunits/minute every 30-40 minutes.
Routine
2 milli-units/min, IntraVENous, As needed, Labor and
Delivery
PRN Comment: _______________________(Required)
If no contractions by 4 milliunits/minute increase rate by 3
milliunits/minute every 30-40 minutes.
Routine
Date:_______ Time:________ Printed Name of Ordering Provider:__________________________________
Provider Signature:_____________________________________________________
Date:_______ Time:_______ RN Acknowledged: _______________________________________________
PROVIDER INITIALS: __________
PATIENT INFORMATION
Page 4 of 4
Outpatient OB [30400732]
PHYSICIAN ORDERS