Download Cardiac Interventions Transfer Orders

CARDIAC INTERVENTIONS
TRANSFER ORDERS
PLACE LABEL HERE
Orders with a “” are choices and are NOT implemented unless checked. All may be altered at physician’s discretion.
TRANSFER DIAGNOSIS: ________________________________________________________________
1. Patient to arrive at ________________ cath lab at ____________ AM/PM on _________________
2. CD/Cath films:
 With physician
3. Diagnostics:
 CBC
 With patient
 Chem 7 in AM
Send copy of results with patient.
4. Send copy of chart with patient. Include: H&P
Lab reports
Carotid study reports
Cardiac study reports
Cath preliminary report
Chest X-ray report
Current MAR including doses given prior to transfer
5.  Femoral sheath to pressurized system with:  Heparinized NS flush
 Normal saline
6. Keep patient flat in bed with HOB elevated no higher than 20°. Keep affected leg straight.
7. Patient actual body weight: ________________kg
8. NPO after: 12 midnight
 Clear liquid breakfast
9. IVF: _______________ at ______________ ml/Hr
 May have medications with sip of water.
Start date and time: _________________
SCHEDULED MEDICATIONS:
10.
Anticoagulant:
 Heparin Drip: follow weight-based protocol for cardiac diagnosis. Stop date/time: ______________
 Arixtra (fondaparinux) 2.5 mg SQ every 24 hours.
 Hold 6 hours before cath/procedure
11.
Hold anti-diabetic agents AM of procedure
12.
Discontinue the following AM medications prior to transfer:
__________________________________________________________________________________
__________________________________________________________________________________
ADDITIONAL ORDERS:
______________________________________________________________________________________
______________________________________________________________________________________
______________
Date
___________________
Time
*1-18791*
FORM 1-18791
_________________________________
Physician Signature
REV. 10/2008
__________
MD Number
Copy to pharmacy _______
(initials)
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