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PHYSICIAN’S PRE-PRINTED ORDERS Centegra Hospital-McHenry Phone: 815-759-4710 Fax: 815-759-4665 Centegra Hospital-Huntley Phone: 224-654-0954 Fax: 815-759-4119 T h INDICATORS/DIAGNOSIS ______________________ e ALLERGY A d u l Name: t REACTION Ht: ______________ Wt: _______________ Smoker: Yes No PRE-CARDIOVERSION ORDERS DOB: Home #: Diagnosis: Scheduled for Date: Procedure: H&P performed by: & Cell #: Time: Permit to read: NPO P six (6) hours prior to procedure unless otherwise ordered by physician. Home Medications per Pre Cardiac/Interventional Radiology Guidelines e give medications with sip of water as instructed by physician, Hold morning dose of digoxin (LANOXIN). May dContinue all anticoagulant medication as usual including morning dose day of procedure. i Continue all antiplatelet medication as usual including morning dose day of procedure a & DIAGNOSTICS (Required diagnostic tests within 30 days please place on chart): LABS Testing Ordered (ICD-10 Code Required) ICD-10 Completed t CBC r BMP i PT c PTT Magnesium c Serum HCG (if not menstrual period free for 1 year) r digoxin (LANOXIN) level if patient on digoxin(LANOXIN) on a admit s physician if patient has taken digoxin (LANOXIN) within 6 hours Call h 12 Lead EKG on admit Insert intravenous catheter on either upper extremity and start 0.9% Normal Saline IV at 100ml/hour unless otherwise indicated, all intravenous fluids require extension tubing c aIV fluids _____________________________________ at______________ mL/hour Insert Saline Lock intravenous catheter on either upper extremity only (no IV fluids to be infused pre-procedure) r if required to have available: Check tdigoxin (LANOXIN) 0.25mg IV verapamil 5mg IV sAnesthesia required for procedure Respiratory Therapy on standby a r e l o c a t 05/16 01/16 PRE CARDIOVERSION ORDERS Page 1 of 1
