Download Outpatient Labs and Supplemention Orders Center for

PLACE LABEL HERE
OUTPATIENT LABS and
SUPPLEMENTION ORDERS
Center For Surgical Weight Management
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
1. Diagnosis: Special Aftercare V58.4 following weightloss surgery 783.3
2. Labs: CBC, Ferritin, B-12, Calcium, Lipid Profile, CMP, Direct Bilirubin, Bone Alkaline Phosphatase
(BAP), Total Vitamin D (25 OH), Hgb A1C (FAX results to 678-312-6241)
3. If levels are within normal range: No treatment indicated.
4. If levels are deficient nurse will call in prescription indicated below:
IRON DEFICIENCY TREATMENT
Hgb > 12 mg/ml and Ferritin > 20:
No treatment Indicated
Hgb 10-12 mg/ml and Ferritin < 20 (mild or moderate deficiency with or without Anemia):
Multigen Plus Caplets, one po daily x 90 days
(calcium, cyanocobalamin, ferrous fumarate, folic acid, succinic acid, iron)
or
If patient needs liquid, Nifrex Elixir 100 mg/ 5 ml, 7.5 ml po once daily x 90 days
(ascorbic acid, biotin, copper, cyanocobalamin, docusate sodium, folic acid, iron, vitamin E)
Hgb < 10 mg/ml and Ferritin < 20 (severe anemia) or refractory to oral treatment: refer to Hematologist
VITAMIN D DEFICIENCY TREATMENT
D 25 OH ( > 30 ng/ml):
No treatment indicated
D 25 OH (20-30 ng/ml): Cholecalciferol (D3) 10,000 international units po daily x 8 weeks
D 25 OH (< 20 ng/ml):
______________
Date
Ergocalciferol (D2) 50,000 international units po daily x 8 weeks
___________________
Time
*1-32226*
_________________________________
Physician Signature
FORM 1-32226 REV. 08/2013
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PID Number
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