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SURGERY LABELS SUBLIMAZE VERSED ___________Mcg/cc AM129-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 AM717-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 FENTANYL AM175-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 AM750-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 ROBINUL KETAMINE AM154-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 DYSPHAGIA HD667-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 AM121-KC 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 ______ EPHEDRINE AM139-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 _ ___ __ _ __ _ __ NEOSTIGMINE ___ ___ ___ mg/ml ___ AM756-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 l ROMAZICON l l l mg/ml l l 4325-123 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 MORPHINE 6700-135 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 EPINEPHRINE 1:10.000/10CC 4325-126 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 FENTANYL 100 mcg/2ml 10 mg/ 1ccl 4325-125 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 GLYCOPYRROLATE Mg/ml VERSED mg/ml AM773-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 mcg/ml AM764-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 12000-120 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 Mg/ml MYOVIEW FENTANYL Midline mg/ml Mcg/cc ___________Mg/cc Midline ______________Mg/cc ATROPINE ________ FILTERED NM700-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 ANECTINE ________Mg/cc AM108-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 LIDOCAINE _______% AM075-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 AM744-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 ALFENTANIL mg/ml AM768-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 NORMAL SALINE 4325-124 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 NEOSYNEPHRINE AM125-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 NORMAL SALINE AM031-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP1 NORMAL SALINE AM141-KG 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 AM141-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 HEPARIN FLUSH DEMEROL ____________UNITS IV111-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 mg/ml AM759-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 Rev 9/06 SURGERY LABELS CABG Ht_____Wt______ BP on both Arms _______________ Antibiotics in OR (1)_____________ TRANSPLANT (2)_____________ 9100-120 2.5" x 2.5" 250 PER ROLL PRICE GROUP 3 13800-158 3" X 4" 300 PER ROLL PRICE GROUP 4 EYE CENTER DATE RECEIVED_____________________ 4325-09 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 VP-SHUNT CART DO NOT USE THIS LOT NUMBER 13800-191 1” X 3” 300 PER ROLL PRICE GROUP 3 Revised: 1/07 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 LR142-K 1.5" X 3" 300 PER ROLL PRICE GROUP 3 SURGERY LABELS * EPIDURAL USE ONLY OPEN HEART * HN758-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 DIFFICULT INTUBATION SAVE 502B 1 1/8" X 1 3/4" 300 PER ROLL PRICE GROUP 5 10850-112 2.5” X 1.75” 500 PER ROLL PRICE GROUP 3 Duramorph CONTACT ANESTHESIA FOR EXTUBATION Administered 10850-43 1.5" X 3" 300 PER ROLL PRICE GROUP 3 + Date:_____Time:___ Follow anesthesia orders for narcotic administration 1st 24 hours. SPINE Room 15 13800-189 1.5" X 3" 300 PER ROLL PRICE GROUP 3 13800-185 2.5” x 2.5” FL PINK 250 PER ROLL Arterial Arterial IMPLANT Venous Venous RUN WITH BIOLOGICAL TEST 10850-168 7/8" X 2.25" 300 PER ROLL PRICE GROUP 2 Revised: 1/07 CS082-K 7/8" X 2.25" 400 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 10850-169 7/8" X 2.25" 300 PER ROLL PRICE GROUP 2 SURGERY LABELS TRAUMA TEAM TRAUMA CAPTAIN Laguna Coast Associates, Inc. REV 1/07 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 10850-162 4” X 6” 100 PER ROLL PRICE GROUP 5 10850-161 4” X 6” 100 PER ROLL PRICE GROUP 5 BIOHAZARD LABELS TRACE _____________________ Chemotherapy Waste 10850-61 4" x 3" 300 PER ROLL PRICE GROUP 5 Start Date: Remove Date: Hazardous Material Incinerate Only BULK _____________________ Chemotherapy Waste Start Date: 10850-62 4" x 3" 300 PER ROLL PRICE GROUP 5 Remove Date: Hazardous Material Incinerate Only Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 BIOHAZARD LABELS BIOHAZARD CONTAMINATED DATE MSDS _________ PC110-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 HEALTH HAZARD ___________________________ PHYSICAL HAZARD ___________________________ ROUTE OF ENTRY ___________________________ TARGET ORGANS ___________________________ MSDS 2871 1" X 3" 320 PER ROLL PRICE GROUP 3 BIOHAZARD BH229-K 1" X 1" 500 PER ROLL PRICE GROUP 2 FLAMMABLE BIOHAZARD 9100-130 3/8” X 1.25” 500 PER ROLL PRICE GROUP 1 CL404-K 2.75” X 2.75” 300 PER ROLL PRICE GROUP 3 BIOHAZARD 3500-52 3/8” X 1.25” 500 PER ROLL PRICE GROUP 1 Revised: 8/05 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 BIOHAZARD LABELS BIOHAZARD BH501-K 8” X 10” 5 PER PKG 14.00/PKG REV. 8/05 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 BIOHAZARD LABELS BIOHAZARD BIOHAZARD NOT EVALUATED FOR INFECTIOUS SUBSTANCES WARNING: Advise patient of communicable disease risks #1 WARNING: Advise patient of communicable disease risks WARNING: Reactive test results for_______________ (Name of disease agent or disease) #2 14900-139 1” x 3” 300 PER ROLL PRICE GROUP 3 14900-140 1” x 3” 300 PER ROLL PRICE GROUP 3 CHEMOTHERAPY CAUTION BIOHAZARD WARNING: Advise patient of communicable disease risks #3 HANDLE WITH GLOVES DISPOSE OF PROPERLY 14900-141 1” x 3” 300 PER ROLL PRICE GROUP 3 _________________ ON302-K 2” X 3” 300 PER ROLL PRICE GROUP 4 CYTOLOGY FIXATIVE POISON LH204-K 7/8” X 2.25 420 PER ROLL PRICE GROUP 2 REV 1/07 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 BIOMED LABELS DO NOT THROW AWAY . . . . . . . . . . . ATTENTION THIS UNIT MUST STAY PLUGGED IN TO MAINTAIN BATTERY 15270-74 2" X 3" 300 PER ROLL PRICE GROUP 4 BE307-K 2.5" X 2.5" 250 PER ROLL PRICE GROUP 3 PREVENTIVE MAINTENANCE Date Due______________________ DEFECTIVE Signature______________________ DO NOT USE BE106-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 DATE:____________________ LOANER BY:______________________ DO NOT REMOVE THIS LABEL BE710-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 BE203-K 2.5" X 2.5" 250 PER ROLL PRICE GROUP 3 Revised: 4/04 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 BIOMED LABELS BIOMEDICAL ENGINEERING DEPT. DO NOT USE SERVICED Date_________________by___________________ Due_______________________________________ Service Performed FT PT ST Do Not Remove Label 10850-163 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 BE275-K 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 FILTER REPLACED ELECTRICAL SAFETY CHECK NON-HOSPITAL OWNED DEVICE Date:____________________________ By:______________________________ RENTAL LOANER EVAL OTHER BY____________________DATE______________ Next Inspection Due________________________ _________________________________________ Technical Dept. DY147-KW 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 BE367-K 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 SERVICED BY RENAL CENTER Date:_______________By:_________________ Due:___________________________________ Repaired Safety Tested Calibrated P.M. 5250 BEGINS______________________ ENDS________________________ DO NOT REMOVE LABEL DY146-K 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 13800-170 1” X 2.5” 300 PER ROLL PRICE GROUP 2 Equipment inspected and assembled by Name_________________________ Date__________________________ 6000-EI 1” X 2.5” 300 PER ROLL PRICE GROUP 2 BH 15270-78 1” X 2.5” 300 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. REV 1/07 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 BLOOD BANK LABELS GLUTARALDEHYDE-28 DAY SOLUTION CORD BLOOD Mixing Date:________________________ Expiration Date:_____________________ Initials:_____________ BB182-K 1" X 3" 300 PER ROLL PRICE GROUP 3 AM308-K 1.5" X 3" 300 PER ROLL PRICE GROUP 3 UNIT NEGATIVE POSITIVE When tested for: __________ Antigen. Date:__________Tech:______ BB736-K BB735-K 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 IRRADIATED BX002-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 DIVIDED BXR950 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 CMV PLASMA PS104-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 RE-DRAW CL415-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 SHARED SPECIMEN SI124-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 VERIFIED BY:_________ NEGATIVE BX008-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 IRRADIATED ABO Group and Rh (if Negative) Confirmed By: Glendale Memorial Hospital L2802 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 BLOOD TYPE CONFIRMED 5720-21 7/8" x 1 5/8" 500 PER ROLL PRICE GROUP 2 CUSTOMIZED PER FACILITY RH-NEGATIVE 13800-154 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 13800-154 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 Revised: 8/04 Laguna Coast Associates, Inc. OB102-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 UNIT POSITIVE When tested for: __________ Antigen. Date:__________Tech:______ BB735-K 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 Unit incompatible with Patient____________________ (Remove this sticker at time of issue) 14800-34 7/8" x 2.25" 420 PER ROLL PRICE GROUP 2 BLOOD BANK LABELS This donor unit No:____has been processed for: PATIENT:____________________________________ HOSPITAL NO:_______________________________ LABORATORY STUDIES PATIENT: ABO Group_____Type:________________ DONOR: ABO Group_____Type:________________ INTERPRETATION OF COMPATIBILTY TESTS: Compatible Emergency Release-Uncrossmatched TECH:______________Date______________________ Patient Name & Med. Rec. Number Specimen Type:________________ Source:_______________________ Collected Date:_________________ Collected Time:_________________ Collected By:___________________ BB310-K 2" X 3" 300 PER ROLL PRICE GROUP 3 5710-02 2.5" x 2.5" 250 PER ROLL PRICE GROUP 3 CENTRIFUGE PERFORMANCE TEST _______________________________________________ Setting Cent. Tach. Photo Tach. _______________________________________________ ___________ ___________ _________________RPM ___________ ___________ _________________RPM ___________ ___________ _________________RPM MAX _________________________________________RPM Timer_______Stopwatch________________________ Date________By_______________________________ Due________Control#___________________________ BE305-K 2" X 3" 300 PER ROLL PRICE GROUP 3 Do Not Leukocyte Reduce OR STAT FOR BLOOD BANK DNLR 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 Revised: 8/04 14900-133 3” X 4” 300 PER ROLL PRICE GROUP 3 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 COMMUNICATION LABELS DIVIDED CMV NEGATIVE BXR950 ROLL OF 900 BB008-K ROLL OF 900 BIOHAZARD BH229-K ROLL OF 250 UNCROSSMATCHED BLOOD PEDIATRIC/NEONATAL COMPONENT LABEL Product________________________Amt_____ BB223-K ROLL OF 420 Patient_________________________________ SANTA MONICA ID #______________________ ABO, Rh______ BXR829-K ROLL OF 900 Donor # __________________ ABO, Rh______ REDRAW SPECIMEN Tech ________________________Date ______ Expire. Date__________________Time ______ 6700-122 ROLL OF 900 SHARE SPECIMEN DO NOT SPIN 6700-121 ROLL OF 900 6700-123 ROLL OF 900 ASPIRIN POOL ONLY BX319-K ROLL OF 320 10 DAYS OLD: 14900-13 ROLL OF 900 14900-18 ROLL OF 420 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 WHOLE BLOOD CPDA-1 WHOLE BLOOD RESUSPENDED IRRADIATED 00101 _____mL From 450 mL CPDA-1 Whole Blood. Store at 1 to 6 C. +5% Hct=50%_ CPDA-1 WHOLE BLOOD Approx. 450 mL plus 63mL CPDA-1. Store at 1 to 6 C. BXR037 BXR046 CPDA-1 WHOLE BLOOD RESUSPENDED IRRADIATED CPDA-1 WHOLE BLOOD 00105 _____mL From 450 mL CPDA-1 Whole Blood. Store at 1 to 6 C. +5% Hct=50%_ 00260 Approx. 450 mL plus 63mL CPDA-1. Store at 1 to 6 C. BXR040 BXR043 Label specifications: 1” X 2.25” Roll of 250 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 00160 WHOLE BLOOD COMPONENT LABELS PRODUCT NAME AND QUALIFIER BARCODE VOL/ANTICOAGULANT DESCRIPTION ORDER # CPDA-1 WHOLE BLOOD RESUSPENDED 00101 ___mL From 450 mL CPDA-1 Whole Blood. Store at 1 to 6 C. Hct=50%__5% + BXR037 CPDA-1 WHOLE BLOOD RESUSPENDED IRRADIATED 00105 ___mL From 450 mL CPDA-1 Whole Blood. Store at 1 to 6 C. Hct=50%__5% + BXR040 CPDA-1 WHOLE BLOOD 00160 Approx. 450 mL plus 63 mL CPDA-1. Store at 1 to 6 C. BXR043 CPDA-1 WHOLE BLOOD IRRADIATED 00260 Approx. 450 mL plus 63 mL CPDA-1. Store at 1 to 6 C. BXR046 CPD WHOLE BLOOD IRRADIATED 00150 Approx. 450 mL plus 63 mL CPD. Store at 1 to 6 C. BXR525 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 RED BLOOD CELLS RED BLOOD CELLS CPD RED BLOOD CELLS WASHED 04900 From 450 mL Whole blood. Store at 1 to 6 C. 04050 From 450 mL CPD Whole Blood. Store at 1 to 6 C. BXR009 BXR013 RED BLOOD CELLS WASHED LEUKOCYTES REDUCED 06000 From 450 mL Whole Blood. Store at 1 to 6 C. BXR061 RED BLOOD CELLS CPD RED BLOOD CELLS WASHED IRRADIATED IRRADIATED 05050 From 450 mL CPD Whole Blood. Store at 1 to 6 C. From 450 mL Whole blood. Store at 1 to 6 C. BXR016 Label specifications: 1” X 2.25” Roll of 250 BXR012 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 05900 RED BLOOD CELLS COMPONENT LABELS PRODUCT NAME AND QUALIFIER BARCODE VOL/ANTICOAGULANT DESCRIPTION ORDER # CPDA-1 RED BLOOD CELLS LEUKOCYTES REDUCED 04360 From 450 mL CPDA-1 Whole Blood Store at 1 to 6 C. BXR019 CPDA-1 RED BLOOD CELLS LEUKOCYTES REDUCED IRRADIATED 05360 From 450 mL CPDA-1 Whole Blood. Store at 1 to 6 C. BXR022 CPDA-1 RED BLOOD CELLS LEUKOCYTES REDUCED DIVIDED 34361 From 450 mL CPDA-1 Whole Blood. Store at 1 to 6 C. BXR063 CPDA-1 RED BLOOD CELLS LEUKOCYTES REDUCED DIVIDED IRRADIATED 35361 From 450 mL CPDA-1 Whole Blood. Store at 1 to 6 C. BXR064 CPDA-1 RED BLOOD CELLS DIVIDED 34161 Approx.___mL from 45 mL CPDA-1 Whole Blood. Store at 1 to 6 C. BXR065 CPDA-1 RED BLOOD CELLS DIVIDED IRRADIATED 35061 Approx.___mL from 45 mL CPDA-1 Whole Blood. Store at 1 to 6 C. BXR066 CPDA-1 RED BLOOD CELLS IRRADIATED 05060 From 450 mL CPDA-1 Whole Blood. Store at 1 to 6 C. BXR048 CPD RED BLOOD CELLS 04050 From 450 mL CPD Whole Blood. Store at 1 to 6 C. BXR013 CPD RED BLOOD CELLS IRRADIATED 05050 BXR016 CPD RED BLOOD CELLS LEUKOCYTES REDUCED 04350 From 450 mL CPD Whole Blood. Store at 1 to 6 C. From 450 mL CPD Whole Blood. Store at 1 to 6 C. CPD RED BLOOD CELLS LEUKOCYTES REDUCED IRRADIATED AS-5 RED BLOOD CELLS ADENINE-SALINE ADDED LEUKOCYTES REDUCED 05350 From 450 mL CPD Whole Blood. Store at 1 to 6 C. 15.0 mEq Sodium added. From 450 mL CPD Whole Blood. Store at 1 to 6 C. BXR034 04750 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 BXR031 BXR020 RED BLOOD CELLS COMPONENT LABELS PRODUCT NAME AND QUALIFIER BARCODE AS-5 RED BLOOD CELLS ADENINE-SALINE ADDED LEUKOCYTES REDUCED IRRADIATED AS-5 RED BLOOD CELLS ADENINE-SALINE ADDED LEUKOCYTES REDUCED DIVIDED IRRADIATED VOL/ANTICOAGULANT DESCRIPTION ORDER # 05750 16.7 mEq Sodium added. From 500 mL CPD Whole Blood. Store at 1 to 6 C. BXR023 35751 15.0 mEq Sodium added. From 450 mL CPD Whole Blood. Store at 1 to 6 C. BXR067 AS-1 RED BLOOD CELLS ADENINE-SALINE ADDED LEUKOCYTES REDUCED DIVIDED AS-1 RED BLOOD CELLS ADENINE-SALINE ADDED LEUKOCYTES REDUCED DIVIDED IRRADIATED 34711 15.4 mEq Sodium added. Approx.___mL from 450 mL CPD Whole Blood. Store at 1 to 6 C. 15.4 mEq Sodium added. Approx.___mL from 450 mL CPD Whole Blood. Store at 1 to 6 C. BXR068 AS-1 RED BLOOD CELLS ADENINE-SALINE ADDED 04210 15.4 mEq Sodium added. From 450 mL CPD Whole Blood. Store at 1 to 6 C. BXR002 AS-1 RED BLOOD CELLS ADENINE-SALINE ADDED IRRADIATED 05210 15.4 mEq Sodium added. From 450 mL CPD Whole Blood. Store at 1 to 6 C. BXR005 AS-1 RED BLOOD CELLS ADENINE-SALINE ADDED DIVIDED 34211 15.4 mEq Sodium added. BXR070 Approx.___mL from 450 mL CPD Whole Blood. Store at 1 to 6 C. AS-1 RED BLOOD CELLS ADENINE-SALINE ADDED DIVIDED IRRADIATED 35211 15.4 mEq Sodium added. BXR071 Approx.___mL from 450 mL CPD Whole Blood. Store at 1 to 6 C. AS-1 RED BLOOD CELLS ADENINE-SALINE ADDED LEUKOCYTES REDUCED 04710 15.4 mEq Sodium added. From 450 mL CPD Whole Blood. Store at 1 to 6 C. BXR001 AS-1 RED BLOOD CELLS 05710 ADENINE-SALINE ADDED LEUKOCYTES REDUCED IRRADIATED 15.4 mEq Sodium added. From 450 mL CPD Whole Blood. Store at 1 to 6 C. BXR004 AS-3 RED BLOOD CELLS ADENINE-SALINE ADDED LEUKOCYTES REDUCED 04730 16.5 mEq Sodium added. From 500 mL CP2D Whole Blood. Store at 1 to 6 C. BXR007 AS-3 RED BLOOD CELLS 05730 ADENINE-SALINE ADDED LEUKOCYTES REDUCED IRRADIATED 16.5 mEq Sodium added. From 500 mL CP2D Whole Blood. Store at 1 to 6 C. BXR010 35711 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 BXR069 RED BLOOD CELLS COMPONENT LABELS PRODUCT NAME AND QUALIFIER BARCODE VOL/ANTICOAGULANT DESCRIPTION ORDER # AS-3 RED BLOOD CELLS ADENINE-SALINE ADDED LEUKOCYTES REDUCED DIVIDED 34731 Approx.___mL from 450 mL CP2D Whole Blood. Store at 1 to 6 C. BXR072 AS-3 RED BLOOD CELLS ADENINE-SALINE ADDED LEUKOCYTES REDUCED DIVIDED IRRADIATED 35731 Approx.___mL from 450 mL CP2D Whole Blood. Store at 1 to 6 C. BXR073 RED BLOOD CELLS SALINE WASHED 04900 From 450 mL Whole Blood. Store at 1 to 6 C. BXR074 RED BLOOD CELLS SALINE WASHED IRRADIATED 05900 From 450 mL Whole Blood. Store at 1 to 6 C. BXR075 RED BLOOD CELLS FROZEN 06200 From 450 mL Whole Blood. Store at -65 or Colder. BXR032 RED BLOOD CELLS FROZEN IRRADIATED 07200 From 450 mL Whole Blood. Store at -65 or Colder. BXR035 RED BLOOD CELLS LEUKOCYTES REDUCED FROZEN 06700 From 450 mL Whole Blood. Store at -65 or Colder. BXR021 RED BLOOD CELLS FROZEN LEUKOCYTES REDUCED IRRADIATED 07700 From 450 mL Whole Blood. Store at -65 or Colder. BXR024 RED BLOOD CELLS DEGLYCEROLIZED 06400 From 450 mL Whole Blood. Store at 1 to 6 C. BXR027 RED BLOOD CELLS DEGLYCEROLIZED IRRADIATED 07400 From 450 mL Whole Blood. Store at 1 to 6 C. BXR030 RED BLOOD CELLS DEGLYCEROLIZED LEUKOCYTES REDUCED 06800 From 450 mL Whole Blood. Store at 1 to 6 C. BXR033 RED BLOOD CELLS 07800 DEGLYCEROLIZED LEUKOCYTES REDUCED IRRADIATED From 450 mL Whole Blood. Store at 1 to 6 C. BXR036 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 RED BLOOD CELLS COMPONENT LABELS VOL/ANTICOAGULANT DESCRIPTION ORDER # 04271 15.0 mEq Sodium added. ___mLs containing approx.___ mL ACDA. Store at 1 to 6 C. BXR0053 AS-3 RED BLOOD CELLS 04771 ADENINE-SALINE ADDED LEUKOCYTES REDUCED (by pheresis) 15.0 mEq Sodium added. ___mLs containing approx.___ mL ACDA. Store at 1 to 6 C. BXR0054 AS-3 RED BLOOD CELLS ADENINE-SALINE ADDED IRRADIATED (by pheresis) 05271 15.0 mEq Sodium added. ___mLs containing approx.___ mL ACDA. Store at 1 to 6 C. BXR0055 AS-3 RED BLOOD CELLS ADENINE-SALINE ADDED LEUKOCYTES REDUCED IRRADIATED (by pheresis) 05771 15.0 mEq Sodium added. ___mLs containing approx.___ mL ACDA. Store at 1 to 6 C. BXR0056 RED BLOOD CELLS WASHED LEUKOCYTES REDUCED IRRADIATED 06100 From 450 mL Whole Blood. Store at 1 to 6 C. BXR062 RED BLOOD CELLS WASHED LEUKOCYTES REDUCED 06000 From 450 mL Whole Blood. Store at 1 to 6 C. BXR061 RED BLOOD CELLS WASHED 04807 From 450 mL CPDA-1 Whole Blood. 0.9% NaCl. Store at 1 to 6 C. CPDA-1 RED BLOOD CELLS 04060 From 450 mL CPDA-1 Whole Blood Store at 1 to 6 C. BXR619 CPDA-1 RED BLOOD CELLS LOW VOLUME 04061 Approx___________mL from___________mL CPDA-1 Whole Blood. Store at 1-6 C. BX366-K PRODUCT NAME AND QUALIFIER BARCODE AS-3 RED BLOOD CELLS ADENINE-SALINE ADDED (by pheresis) Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 5085 PLATELETS PLATELETS PLATELETS PHERESIS IRRADIATED PHERESIS _____mL containing approx._____mL of ACDA Anticoagulant. Store at 20 to 24 C. 12010 _____mL containing approx._____mL of ACDA Anticoagulant. Store at 20 to 24 C. BXR038 12610 BXR041 PLATELETS PHERESIS LEUKOCYTES REDUCED _____mL containing approx._____mL of ACDA Anticoagulant. Store at 20 to 24 C. 12710 BXR050 PLATELETS PLATELETS PHERESIS LEUKOCYTES REDUCED IRRADIATED _____mL containing approx._____mL of ACDA Anticoagulant. Store at 20 to 24 C. IRRADIATED 12810 Approx. 45-65 mL from 450 mL CPD Whole Blood. Store at 20 to 24 C. BXR053 Label specifications: 1” X 2.25” Roll of 250 BXR052 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 12600 PLATELETS COMPONENT LABELS PRODUCT NAME AND QUALIFIER BARCODE VOL/ANTICOAGULANT DESCRIPTION ORDER # PLATELETS IRRADIATED 12600 Approx. 45-65 mL from 450 mL BXR052 CPD Whole Blood. Store at 20 to 24 C. PLATELETS POOLED 12091 Approx.___mL From ___donors. BXR076 Collected in CPD. Store at 20 to 24 C. PLATELETS POOLED IRRADIATED 12691 Approx.___mL From ___donors. BXR006 Collected in CPD. Store at 20 to 24 C. PLATELETS PHERESIS 12010 ___mL containing approx.___ mL of ___Anticoagulant. Store at 20 to 24 C. BXR038 PLATELETS PHERESIS IRRADIATED 12610 ___mL containing approx.___ mL of ___Anticoagulant. Store at 20 to 24 C. BXR041 PLATELETS PHERESIS DIVIDED 52011 ___mL containing approx.___ mL___ACD-A. Store at 20 to 24 C. BXR077 PLATELETS PHERESIS DIVIDED IRRADIATED 52611 ___mL containing approx.___ mL___ACD-A. Store at 20 to 24 C. BXR078 PLATELETS PHERESIS LEUKOCYTES REDUCED 12710 ___mL containing approx.___ mL of ___Anticoagulant. Store at 20 to 24 C. BXR050 PLATELETS PHERESIS LEUKOCYTES REDUCED IRRADIATED 12810 ___mL containing approx.___ mL of ___Anticoagulant. Store at 20 to 24 C. BXR053 PLATELETS PHERESIS LEUKOCYTES REDUCED DIVIDED 52711 ___mL containing approx.___ mL___ACD-A. Store at 20 to 24 C. BXR079 PLATELETS PHERESIS LEUKOCYTES REDUCED DIVIDED IRRADIATED 52811 ___mL containing approx.___ mL___ACD-A. Store at 20 to 24 C. BXR080 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 PLASMA FRESH FROZEN PLASMA _____mL From 450 mL CPDA-1 Whole Blood. Store at -18 C or colder. FRESH FROZEN PLASMA DIVIDED UNIT Approx. 80 mL from 450 mL CPDA-1 Whole Blood. Store at -18 C or colder. 18201 18200 BX373-K 7005 FRESH FROZEN PLASMA FRESH FROZEN PLASMA AUTOMATED PHERESIS _____mL containing approx. _____mL of ACD-A Anticoagulant Store at -18 C or colder. 18211 _____mL From 450 mL CPD Whole Blood. Store at -18 C or colder. FRESH FROZEN PLASMA _____mL containing approx. _____mL of ACD-A Anticoagulant Store at -18 C or colder. 18211 2800 PLASMA AHF REMOVED 18201 18402 Approx 225 mL from CPDA-1 Whole Blood. Store below -18 C 2804 BX330-K PLASMA FRESH FROZEN PLASMA PLASMA FROZEN PHERESIS-DIVIDED Within 24 Hours After Phlebotomy CRYOPRECIPITATE REDUCED ___________mL from 500mL CPD Whole Blood. Store at -18 C or colder. _____mL containing approx. _____mL of ACD-A Anticoagualnt. Store at -18 C or colder. 18435 BXR905 BXR900 48211 _____mL from 450 mL CPD Whole blood. Store at -18 C or colder. BXR822 18101 BXR823 PLASMA FROZEN PLASMA FROZEN PLASMA FROZEN Within 24 Hours After Phlebotomy Within 24 Hours After Phlebotomy DIVIDED 18101 Within 24 Hours After Phlebotomy DIVIDED 18101 _____mL from 450 mL CPDA-1 Whole blood. Store at -18 C or colder. 18101 _____mL from 450 mL CPD Whole blood. Store at -18 C or colder. BXR824 _____mL from 450 mL CPDA-1 Whole blood. Store at -18 C or colder. BXR825 Label specifications: 1” X 2.25” Roll of 250 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 BXR826 CRYOPRECIPITATED CRYOPRECIPITATED AHF POOLED No. Pooled Units_____. Volume_____mL From 450 mL CPD 10191 Whole Blood. Store at 20 to 24 C. BX375-K MISC. See circular of informatino for indications, contraindications, cautions and methods of infusion. VOLUNTEER DONOR This product may transmit infectious agents. Caution: Federal law prohibits dispensing without a perscription. PROPERLY IDENTIFY INTENDED RECIPIENT BXR799 Label specifications: 1” X 2.25” Roll of 250 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 BASE LABELS Collection Date Donation Number EXPIRES Place Blood Component Label here after bag is filled. Affix grouping label here after all required testing has been completed. See Circular of Information for indications, contraindications, cautions, and methods of infusion. VOLUNTEER DONOR This product may transmit infectious agents. CAUTION: Federal law prohibits dispensing without a prescription. PROPERLY IDENTIFY INTENDED RECIPIENT Affix Collection/Processing I.D. Label Here BX501-K 3" X 4" ROLL OF 250 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 MANUFACTURING LABELS RECOVERED PLASMA LIQUID CAUTION: FOR MANUFACTURING 19501 USE ONLY _________mL from 450 mL CPDA-1 Whole Blood. Store at 10 C or colder. RECOVERED PLASMA LIQUID CAUTION: FOR MANUFACTURING 19501 USE ONLY ___________________________________ _________mL from 450 mL CPDA-1 Whole Blood. Store at 37 C or colder. NAME, CITY OF INSTITUTION Separated at (if different than collecting facility) Negative for antibodies to HIV, HCV, HTLV I/II and nonreactive for HB sAg, STS, HCV RNA, and HIV-1 RNA by FDA required tests. ___________________________________ Separated at (if different than collecting facility) Collected on: NAME, CITY OF INSTITUTION Negative by a test for antibody to HIV and HCV, nonreactive for HBsAg. Collected on: ___________________________________ ___________________________________ BX436-K ROLL OF 250 BX435-KC ROLL OF 250 RECOVERED PLASMA LIQUID CAUTION: FOR MANUFACTURING 19501 USE ONLY RECOVERED PLASMA CAUTION: FOR MANUFACTURING 19601 USE ONLY _________mL from 450 mL CPD Whole Blood. Store at 10 C or colder. _________mL from 450 mL CPDA-1 Whole Blood. Store at -18 C or colder. Separated at (if different than collecting facility) Separated at (if different than collecting facility) ___________________________________ ___________________________________ NAME, CITY OF INSTITUTION NAME, CITY OF INSTITUTION Negative for antibodies to HIV, HCV, HTLV I/II and nonreactive for HB sAg, STS, HCV RNA, and HIV-1 RNA by FDA required tests. Negative by tests for HIV-1 antigen(s), antibodies to HIV and HCV, and nonreactive for HBsAg by FDA required tests. Collected on: This product may transmit infectious agents. Collected on: ___________________________________ ___________________________________ BX437-KC ROLL OF 250 3708 ROLL OF 250 RECOVERED PLASMA PLATELETS CAUTION: FOR USE IN MANUFACTURING 19201 NONINJECTABLE PRODUCTS ONLY CAUTION: FOR USE IN MANUFACTURING 22001 NONINJECTABLE PRODUCTS ONLY Not For Use in Products Subject Not For Use in Products Subject _________mL from to License Under Section 351 of the Public Health Service Act. 450 mL CPDA-1 Whole Blood. Store at 37 C or colder. to License Under Section 351 of _____mL from the Public Health Service Act. _____mL Whole Blood plus_____mL_____ anticoagulant. Store at 37 C or colder. Separated at (if different than collecting facility) ___________________________________ NAME, CITY OF INSTITUTION Negative by a test for antibody to HIV and HCV, nonreactive for HBS Ag. Collected on: Negative by a test for antibody to HIV, HBc and HCV, nonreactive for HBS Ag. Collected on: ___________________________________ BX434-K ROLL OF 250 ___________________________________ Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 BX432-K ROLL OF 250 REVISED 3/10/04 MANUFACTURING LABELS SOURCE LEUKOCYTES RECOVERED PLASMA FRESH FROZEN CAUTION: FOR RESEARCH 20301 USE ONLY CAUTION: FOR MANUFACTURING 19801 USE ONLY ___mL from 450 mL Whole Blood plus 63 mL CPD. Store at 20 to 24 C. ___mL from 450 mL CPDA-1 Whole Blood. o Store at -18 C or colder. Caution: Do not use contents until results for HIV-1 antigen(s), HBsAg, and HCV testing have been received from collection facility. This product may transmit infectious agents. Negative for antibodies to HIV, HCV, HTLV I/II and nonreactive for HBsAg, STS, HCV RNA, and HIV-1 RNA by FDA required tests. Collected on: Collected on: __________________________ __________________________ 3903 14900-130 RECOVERED PLASMA FRESH FROZEN CAUTION: FOR MANUFACTURING 19801 USE ONLY ___mL from 450 mL CPD Whole Blood. Store at -18oC or colder. Negative for antibodies to HIV, HCV, HTLV I/II and nonreactive for HBsAg, STS, HCV RNA, and HIV-1 RNA by FDA required tests. Collected on __________________________ 14900-122 Label specifications: 2.5" X 2.5" Roll of 250 REVISED 3/22/04 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 ABO LABELS O O A A Rh NEGATIVE Rh POSITIVE Rh NEGATIVE Rh POSITIVE BX231-K ROLL OF 250 BX235-K ROLL OF 250 BX232-K ROLL OF 250 BX236-K ROLL OF 250 B B AB AB Rh NEGATIVE Rh POSITIVE Rh NEGATIVE Rh POSITIVE BX233-K ROLL OF 250 BX237-K ROLL OF 250 BX234-K ROLL OF 250 BX238-K ROLL OF 250 EXPIRES EXPIRES EXPIRES O O A EXPIRES A Rh NEGATIVE Rh POSITIVE Rh NEGATIVE Rh POSITIVE BX242-K ROLL OF 250 BX246-K ROLL OF 250 BX239-K ROLL OF 250 BX243-K ROLL OF 250 EXPIRES EXPIRES EXPIRES EXPIRES B B AB AB Rh NEGATIVE Rh POSITIVE Rh NEGATIVE Rh POSITIVE BX240-K ROLL OF 250 BX244-K ROLL OF 250 BX241-K ROLL OF 250 BX245-K ROLL OF 250 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 CENTRAL SUPPLY DISINFECTED IMPLANT RELEASE TAG SET_______________________________ RELEASE DATE_____________________ DATE______#_____ LOAD STICKER 11200-04 1" X 3" 300 PER ROLL PRICE GROUP 3 8225-02 1" X 2.5" 300 PER ROLL PRICE GROUP 2 THIS TRAY EXPIRES AERATED O.K. TO USE DATE________________ INIT__________________ CS165-K 7/8" X 2 1/4" 420 PER ROLL PRICE GROUP 2 12000-34 1" X 2.5" 300 PER ROLL PRICE GROUP 2 STERILE DUST COVER THIS ITEM Unless Package Opened Damaged or Wet 10850-35 7/8" X 2 1/4" 420 PER ROLL PRICE GROUP 2 DC-P 1" X 2.5" 300 PER ROLL PRICE GROUP 2 THIS ITEM CLEAN NOT STERILE ASSEMBLED AND CHECKED IN BY__________________________ CS230-K 7/8" X 2 1/4" 420 PER ROLL PRICE GROUP 2 DATE________________________ OR-1152 1" X 2.5" 300 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 CENTRAL SUPPLY STERILE HOUSE SUPPLY Package expiration event-related only. Check package integrity. If not intact, DO NOT USE!! 13300-102 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 6699-01 1.5" X 3" 300 PER ROLL PRICE GROUP 3 EXPIRED DATE_____________________ DO NOT MR211-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 COUNT 3840-25 1.5" X 3" 300 PER ROLL PRICE GROUP 3 ALERT: SEND FAILED SENSOR AND THIS LOT IS READY FOR USE DATE_________INIT_____ QC223-K 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 NEW LOT DO NOT USE QC202-K 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 Rec'd _______________ CALIBRATION STRIP TO SPD DO NOT DISCARD 12000-112 1.5" X 3" 300 PER ROLL PRICE GROUP 3 Init. Opened _____________ Init. 182943 3/8" x 1.25" 500 PER ROLL PRICE GROUP 1 SNF HOUSE SUPPLY 3840-05 3/8" x 1.25" 500 PER ROLL PRICE GROUP 1 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 USE FIRST QC101-K 3/8" x 1.25" 500 PER ROLL PRICE GROUP 1 AUTO SUB 13300-131 3/8" x 1.25" 500 PER ROLL PRICE GROUP 1 CENTRAL SUPPLY NOTICE IMPLANTABLE ITEM Sterilize with Biological Indicator/Test CS317-K 1" X 3" 300 PER ROLL PRICE GROUP 3 This Tray is Incomplete WARNING GAS STERILIZE ONLY Missing____________________ ____________________________ ____________________________ Date:________________________ STERILITY GUARANTEED UNTIL THE PACKAGE IS DAMAGED OR OPENED CS322-K 4" X 3" 300 PER ROLL PRICE GROUP 5 STAT 6700-32 2" X 3" 300 PER ROLL PRICE GROUP 3 Revised: 4/04 ICMC-02 1" X 2.5" 300 PER ROLL PRICE GROUP 2 Date opened:______________ Exp. date:_________________ By:#_____________________ CS650-K 1" X 1" 500 PER ROLL PRICE GROUP 2 Rec'd____Intl_____ Opened___Intl____ 182942 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 12700-12 3/8" x 1.25" 500 PER ROLL PRICE GROUP 1 Date Rec'd ______________ Date Opened ____________ Exp. Date _______________ LR138-K 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 CENTRAL SUPPLY CLEAN This Tray Is INCOMPLETE CAUTION Missing____________ ___________________ ___________________ ____________Date___ 10850-113 1” X 3” 300 PER ROLL PRICE GROUP 3 DIRTY 13800-160 2.5” x 1.75” 500 PER ROLL PRICE GROUP 3 WATCH EXPIRATION DATE CS258-K 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 CLEAN 10850-114 1” X 3” 300 PER ROLL PRICE GROUP 3 CS716-K 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 FILL WITH DISTILLED WATER ONLY TERMINATED__________ SHIP ON______________ ******************************* 7025-38 1.5” X 3” 300 PER ROLL PRICE GROUP 3 CS246-K 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 AUTOCLAVED ON____________ EXPIRES ON________________ RETURN TO CENTRAL SERVICE FOR RE-STERILIZATION CS172-K 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 Revised: 1/07 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 CENTRAL SUPPLY DAMAGED EXPEDIATE BACK TO OPC 10850-126 3” X 2” WHITE W/BLK PRINT 300 PER ROLL PRICE GROUP 3 10850-111 3” X 2” FL. GREEN 300 PER ROLL PRICE GROUP 3 Vinegar Bleach Heat Sterilized Date_______ Initials_____ RETURN TO CENTRAL SERVICE CS269-K 7/8" X 2 1/4" 420 PER ROLL PRICE GROUP 2 DY145-K 1” X 3” 300 PER ROLL PRICE GROUP 3 P.I.C.C. 6700-136 3/8” X 1.25” FL YELLOW 500 PER ROLL PRICE GROUP 1 Company Name:_________________________ Attn:___________________________________ Address:_______________________________ 14295-11 3” X 4” 300 PER ROLL PRICE GROUP 5 _______________________________ _______________________________ Return P.O.#:____________________________ RGA#__________________________________ REV 1/07 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 CHARGE LABELS FOR HEALTHCODER OR DIRECT THERMAL PRINTERS AHC8-YC 1.5" X 15/16" 3000 PER ROLL HC8-OCC 1.5" X 15/16" 3000 PER ROLL FOR THERMAL TRANSFER PRINTERS HC8-WHITE 1.5" X 15/16" 3000 PER ROLL TPB3-YRNZ 7/8" X 1.5" 3700 PER ROLL TPB3-ORNZ 7/8" X 1.5" 3700 PER ROLL HC8-PC 1.5" X 15/16" 3000 PER ROLL TPB3-BRNZ 7/8" X 1.5" 3700 PER ROLL HC8-BC 1.5" X 15/16" 3000 PER ROLL RBCL-R 3/4" X 1 5/8" REMOVABLE 3700 PER ROLL SINGLE PLY HC8-GC 1.5" X 15/16" 3000 PER ROLL Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 CHARGE LABELS FOR DIRECT THERMAL PRINTERS S78-178PBY 7/8" X 1 7/8" 3500 PER ROLL S78-178PBW 7/8" X 1 7/8" 3500 PER ROLL S78-178PB0 7/8" X 1 7/8" 3500 PER ROLL S78-178PBG 7/8" X 1 7/8" 3500 PER ROLL S78-178PBB 7/8" X 1 7/8" 3500 PER ROLL S78-178PBV 7/8" X 1 7/8" 3500 PER ROLL Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 DIETARY LABELS SMALL PORTIONS HD176-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 Tuna Salad HD619-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 THICK LIQUIDS ONLY HD643-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 PUREED HD190-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 No Citrus HD173-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 NO MILK OR MILK PRODUCTS HD600-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 Turkey FLUID RESTRICTION _________________CC/24 HRS ATTENTION: CALORIE COUNT Please :*SAVE MENUS from each meal and between snacks *WRITE AMOUNTS of foods/beverages eaten on menus *PLACE MENUS in this ENVELOPE 15270-25 7/8" X 2.25" 300 PER ROLL PRICE GROUP 2 A dietitian or dietetic technician will use this information to calculate daily nutrition intakes. Name ______________Rm.# _______Date _______ DIABETIC HD340-K 2" X 3" 300 PER ROLL PRICE GROUP 3 HH217-K 1" X 2.5" 300 PER ROLL PRICE GROUP 2 NO FLUID ON TRAY THIS IS NOT A UNIT DOSE CONTAINER HD268-K 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 DO NOT GIVE ENTIRE CONTENTS 15600-36 1" X 2.5" 300 PER ROLL PRICE GROUP 2 NOURISHMENT Name______________Rm_____Date_____ Food Allergies _________________ _________________ Diet________________________________ ____________________________________ Serving Time______AM____PM____H.S. 15270-22 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 HD304-K 1.5" X 3" 300 PER ROLL PRICE GROUP 3 Laguna Coast Associates, Inc. REV 1/07 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 HD219-K 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 NO CONCENTRATED SWEETS HD661-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 DIETARY LABELS NAME_______________________________ ROOM____________DATE______________ NUTRITION evaluation has been completed. Please see report under “Progress Notes” for details. RECOMMEND:_________________________________ _____________________________________________ _____________________________________________ ______________________________________________ ______________________________________________ Agree Disagree (Food Service to contact MD) ________________________ ___________________ Physician’s Signature Date 6 VANILLA WAFERS, 8OZ LFM ____________________________________ TIME:_____AM______PM______HS 15270-113 1” X 3” 300 PER ROLL PRICE GROUP 2 NAME_______________________________ ROOM____________DATE______________ 2 PKTS GRAHAM CRAX, 8OZ LFM ____________________________________ TIME:_____AM______PM______HS 15270-112 1” X 3” 300 PER ROLL PRICE GROUP 2 SH111 3” X 4” 300 PER ROLL PRICE GROUP4 NUTRITION SCREENING COMPLETED OLYMPIA MEDICAL CENTER NUTRITION NOTE Patient Is Receiving Routine Nutrition Services at This Time. Nutritional Risk Factor Identified. Priority Level _________ Nutritional Recommendations Will Follow. Comprehensive Nutritional Assessment Is Recommended. Calorie count initiated at______ on_________. Results to follow. _________________ Dietician _____________ Date 9000-37 1.5” x 3” 300 PER ROLL PRICE GROUP 3 REVISED 1/07 Dietician___________________Date__________________ DRY TRAY 9000-38 1.5” x 3” 300 PER ROLL PRICE GROUP 3 50000-32 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 FILING LABELS NF310-RED NF311-GRAY NF312-BLUE NF313-ORANGE NF314-PURPLE NF315-BLACK NF316-YELLOW NF317-BROWN NF318-PINK NF319-GREEN 00 * ALL OF THE ABOVE ARE AMES COMPATIBLE 07 07 2007 YEAR LABELS AVAILABLE IN: PEACH BROWN TEAL/LIME GRAY RED BLACK PURPLE 1 7/8" x 1 7/8" 07 07 3/4" x 1 1/2" 2 0 0 7 11-060 REV 1/07 2 0 0 7 2 0 2 0 0 7 11-095 0 7 07 07 1/2" x 1" Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 M M 5720-57 1.5” X .5” 500 PER ROLL PRICE GROUP 2 FILING LABELS FFP400-L YELLOW FFP401-L BLUE FFP402-L PINK FFP403-L PURPLE FFP404-L ORANGE FFP405-L BROWN FFP406-L GREEN FFP407-L GRAY FFP408-L RED FFP409-L BLACK 00 2 X 1 1/2 * ALL OF THE ABOVE ARE SMEAD COMPATIBLE 67340 YELLOW 67341 BLUE 67342 PINK 67343 PURPLE 67344 ORANGE 67345 BROWN 67346 GREEN 67347 GRAY 67348 RED 67349 BLACK 00 1 X 1 1/4 * ALL OF THE ABOVE ARE SMEAD COMPATIBLE 2007 YEAR LABELS 07 07 1.75 X ½ 2006 YELLOW Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 FILING LABELS 67340 YELLOW 67341 BLUE 67342 PINK 67343 PURPLE 67344 ORANGE 67345 BROWN 67346 GREEN 67347 GRAY 67348 RED 67349 BLACK 00 1 X 1 1/4 * ALL OF THE ABOVE ARE SMEAD COMPATIBLE 04 04 06 06 3/4" x 1 1/2" RS11-090-06 YELLOW RS11-090-05 FL PINK RS11-090-04 GREEN RE11-090-03 PURPLE RS11-090-02 RED RS11-090-01 BLACK RS11-090-00 BLUE RS11-090-99 ORANGE Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 LAB LABELS 10856IRZ IR MATERIAL 4 x 1.25 WHITE BLANK 3600PER ROLL MEDITECH 10856PINKZ IR MATERIAL 4 x 1.25 LT PINK STRIPE 3600PER ROLL MEDITECH Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 LAB LABELS ----------- FOR THERMAL PRINTERS ------------------- 8006-1 IR MATERIAL 4 ½ X 4 3/16 W/SLITS 1000/ROLL CERNER REVISED 9/22/04 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 LAB LABELS . 12345678 12345678 12345678 ½X1½ CONSECUTIVE NUMBER I UP Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 LAB LABELS 10% FORMALIN 24 HOUR URINE COLLECTION CAUTION CONTAINS FORMALDEHYDE Toxic by inhalation and if swallowed. Irritating to the eye, respiratory system, and skin. May cause sensitization by inhalation or skin contact. Risk of serious damage to eyes. May cause cancer. Repeated or prolonged exposure increases the risk. PATIENT________________________ROOM NO.________ START DATE & TIME_______________________________ CL242-K 1" X 2.5" 300 PER ROLL PRICE GROUP 2 END DATE & TIME_________________________________ NAME OF TEST___________________________________ BLOOD GROUP AND Rh TYPE RECHECKED BY PRESERVATIVE___________________________________ TECH__________________ HOSP__________________ DATE__________________ Date Prepared__________________Tech Code_________ SB-70 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 2% GLUTARALDEHYDE IN 0.2M SODIUM CACODYLATE BUFFER 00 4 11 Surg#____________________________ Patient Name______________________ MDACC#__________________________ MSDS2871 7/8" X 3" 320 PER ROLL PRICE GROUP 5 12000-70 3" x 4" 300 PER ROLL PRICE GROUP 4 CAUTION: Contains FORMALDEHYDE. Toxic by inhalation and if swallowed. Irritating to the eyes, respiratory system and skin. May cause sensitization by inhalation or skin contact. Risk of serious damage to eyes. May cause cancer. Repeated or prolonged exposure increases the risk. CL223-K 1" X 3" 300 PER ROLL PRICE GROUP 3 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 LAB LABELS FOR THERMAL PRINTERS 10856P-3600 NON- IR 4 x 1.25 RED BORDER 3600 PER ROLL MEDITECH FOR ELTRON PRINTER 28389B NON- IR 4 x 1.25 RED BORDER 1250 PER ROLL MEDITECH 10856-3600 NON-IR 4 x 1.25 WHITE BLANK 3600PER ROLL MEDITECH FOR ELTRON PRINTER 28389 NON- IR 4 x 1.25 WHITE BLANK 1250 PER ROLL MEDITECH 10856IRZ IR MATERIAL 4 x 1.25 WHITE BLANK 3600PER ROLL MEDITECH 10856PINKZ IR MATERIAL 4 x 1.25 LT PINK STRIPE 3600PER ROLL MEDITECH Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 LAB LABELS FOR THERMAL PRINTERS 2100-LF-B NON- IR 4 x 1.25 PINK BORDER 3000 PER ROLL FARGO 2100-LF-W NON-IR 4 x 1.25 WHITE BLANK 3000 PER ROLL FARGO 2100-LF-W3600 4 X 1.25 WHITE BLANK 3600 PER ROLL FARGO 2100-LF-BRED NON-IR 4 X 1.25 WHITE WITH RED BAR ON BOTTOM 3600/ROLL FARGO 2100LAB-FARGOZ 4 x 1.25 WHITE BLANK 3000 PER ROLL FARGO- SLIT OFFSET Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 REVISED 10/04 LAB LABELS FOR THERMAL PRINTERS 10856Y-5 NON-IR 4 x 1.25 YELLOW BLANK 5000 PER ROLL MEDITECH 10856P-5 IR MATERIAL 4 x 1.25 PINK BLANK 5000 PER ROLL MEDITECH Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 LAB LABELS FOR THERMAL PRINTERS _____ ____ SQ-4PINKZ 4 1/4 X 1 3/16 4300/ROLL SUNQUEST _____ ____ ____ _____ SQ-4WHITEZ 4 1/4 X 1 3/16 4300/ROLL SUNQUEST SQ-4YELLOWZ 4 1/4 X 1 3/16 4300/ROLL SUNQUEST SQ-104DT WHITE SQ-104DTY YELLOW SQ-104DTP LT PINK SQ-104DTB LT BLUE 4 1/4 X 1 3/16 1500/ROLL SUNQUEST ____ _____ FOR BARCODE BLAZER PRINTERS SQ-104DTB LT BLUE 4 1/4 X 1 3/16 1500/ROLL SUNQUEST Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 LAB LABELS FOR THERMAL PRINTERS 8006 IR MATERIAL 4 1/2 X 4 3/16 W/SLITS 1000/ROLL CERNER CL-0141 NON-IR MATERIAL 4 1/2 X 4 3/16 W/SLITS 1000/ROLL 2 ROLLS/CTN CERNER Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 LAB LABELS FOR THERMAL PRINTERS 8006-R IR MATERIAL 4 1/2 X 4 3/16 W/SLITS 1000/ROLL RED BORDER CERNER Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 LAB LABELS FOR THERMAL PRINTERS CTN-1 KIT 3 ROLLS/1 RIBBON 3 1/8 X 1 W/SLITS 5000/ROLL 15000/CTN CITATION _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1650R 3 ROLLS/1 RIBBON 3 1/8 X 1 1/4 W/SLITS 4200/ROLL 12600/CTN CITATION Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 LAB LABELS CL3-GOLVE 8 1/4 X 1 15/6 CARRIER WIDTH 9 1/2 2500/CTN CITATION SQ-MICRO SLIDE 15/16 X 15/16 6 UP 30M /CTN Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 ________ ________ ________ __ __ ___ __ ___ __ ___ __ FOR PINFEED PRINTERS LAB LABELS _ _ _ _ _ _ _ _ ________ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ FOR PINFEED PRINTERS _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ DPSQ-105 8 1/4 X 3 1/2 CARRIER WIDTH 9 2000/CTN SUNQUEST L-SQ-6C 8 3/16 X 5 1/2 CARRIER WIDTH 9 1000/CTN SUNQUEST Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 LAB LABELS FOR THERMAL PRINTERS CL-100S-3DT DIRECT THERMAL 2-UP 0390A DIRECT THERMAL 2.4X4 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 03/29/04 LAB LABELS ___________________HOUR URINE COLLECTION TESTS REQUESTED: 1.___________________________ 2.___________________________ 3.___________________________ PRESERVATIVE:_________________________________ ADDED BY________________________________ COLLECTION STARTED:__________________________ (Time) (Date) COLLECTION COMPLETE:________________________ (Date) (Time) KEEP SPECIMEN REFRIGERATED DURING COLLECTION UPCR-9106 1.5” X 3” 300 PER ROLL PRICE GROUP 3 KEEP SPECIMEN REFRIGERATED DURING COLLECTION UPCR-9107 1.5” X 3” 300 PER ROLL PRICE GROUP 3 CL313-K 3” X 2” 300 PER ROLL PRICE GROUP 4 PHONE REPORT FAX RESULTS HI113-K 3/8” X 1.25” 500 PER ROLL PRICE GROUP 1 CL128-K 3/8” X 1.25” 500 PER ROLL PRICE GROUP 1 FROZEN CULTURE & SENSITIVITY Item____________________Intls._______ AM Prep Date_____________Time_______PM AM Use by________________Time______ PM 10850-118 1” X 3” 300 PER ROLL PRICE GROUP 3 HT145-K 3/8” X 1.25” 500 PER ROLL PRICE GROUP 1 CMV POSITIVE 14900-138 3/8” X 1.25” 500 PER ROLL PRICE GROUP 1 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 MI164-K 3/8” X 1.25” 500 PER ROLL PRICE GROUP 1 CMV NEGATIVE BX050-K 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 Revised 1/07 LAB LABELS FOR ELTRON OR E CLASS DATAMAX DTLE4020PS DIRECT THERMAL LABELS 1000/RLL 1”CORE 800530-205Z 3X2 DIRECT THERAL LABEL 735/ROLL 1” CORE DTLE4020P DIRECT THERMAL LABELS 735/ROLL 1” CORE Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 LAB LABELS FOR ELTRON OR E CLASS DATAMAX 800522-125 2.25X1.25 DIRECT THERMAL 1135/ROLL 1” CORE Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 LAB LABELS COH-CYTOLOGY: PAP SMEAR POISON 95%ETOH-STORED: RM TEMP POISON 95%ETOH-STORED: RM TEMP NAME: CHART#: DATE MADE: DATE MADE: EXP. DATE: EXP. DATE: COH-11 2.5” X 2.5” 250 PER ROLL PRICE GROUP 3 COH-12 2.5” X 2.5” 250 PER ROLL PRICE GROUP 3 Laguna Coast Associates, Inc. REV 1/07 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 MEDICAL RECORDS DOCTOR, in case I miss you... _______________________________ _______________________________ _______________________________ _______________________________ From______________________ NOT CODED MR728-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 ROUTE TO CODER WHEN DISCHARGE SUMMARY INSERTED MR295-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 3840-09 3" x 4" 300 PER ROLL PRICE GROUP 4 RETURN TO CODING ____________________ FULL CODE 15270-115 1” X 3” FL YELLOW 300 PER ROLL PRICE GROUP 2 CODED MR292-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 MR293-K 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 RETURN TO CODER WHEN____________ INSERTED. RETURN TO CODING PERMANENT FILE MR254-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 REV 9/06 ____________________ 1325-121 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 MR727-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 MEDICAL RECORDS PROTECTED HEALTH INFORMATION CONFIDENTIAL DO NOT FAX OR COPY HC807-K 1" X 3" 300 PER ROLL PRICE GROUP 3 THIS IS AN INCOMPLETE RECORD MR225-K 1" X 3" 300 PER ROLL PRICE GROUP 3 Please.... SIGN HERE 50000-03 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 DICTATION NEEDED 2625-14 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 PSYCHIATRIC RECORD DO NOT REMOVE FROM MEDICAL RECORD DEPARTMENT MR243-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 COMPLETE DISCHARGE SUMMARY 50000-14 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 LEGAL GUARDIAN NAME:___________________________ PHONE:____________________________ 50000-04 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 Revised 9/06 SY302-K 1.5” X 3” WHITE W/BLK PRINT 300 PER ROLL PRICE GROUP 3 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 MEDICAL RECORDS Advance Directive On File INTERNAL PROCESSING CHECK LIST ______ ______ ______ ______ ______ ______ ______ ______ Assembling Analyzing for deficiencies Abstracting Coding DATE_____________ MR430-K 2.5" X 2.5" Fl. Green 250 PER ROLL PRICE GROUP 3 MR224-K 2.5" X 2.5" 250 PER ROLL PRICE GROUP 3 ADVANCE DIRECTIVE ______________________ ON FILE DATE _______ Patient has no _____________Advance Directive __________ _____________Do Not Resuscitate __________ _____________Living Will Durable Power of _____________Attorney Health Care _____________Surrogate __________ Patient’s Name: PENDING DISCHARGE __________ __________ _____________ ________________(OTHER) __________ MR433-K 4” X 3” FL. PINK 300 PER ROLL PRICE GROUP 4 Revised 9/06 50000-19 1” X 2.5” FL. PINK 300 PER ROLL PRICE GROUP 2 PENDING DISCHARGE 50000-20 3/8” X 1.25” FL PINK 500 PER ROLL PRICE GROUP 1 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 MEDICAL RECORDS NAME ALERT Name Alert Two patients __________________ with same name HN299-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 OUT OF COUNTY MEDICAL 50000-18 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 6700-72 7/8" x 1 5/8" 500 PER ROLL PRICE GROUP 2 Chart Thinned UNSEARCHED Pt. Name___________________ Date Thinned Initials 1._____From:___To:___By:_____ 2._____From:___To:___By:_____ 3._____From:___To:___By:_____ Date__________ name_________ HN305-K 1.5" X 3" 300 PER ROLL PRICE GROUP 3 Verbal/Phone Authentication 50000-22 4” x 3” FL ORANGE 300 PER ROLL PRICE GROUP 5 MD_____________________ DATE________TIME_______ LOOK ALIKE SOUND ALIKE 12100-01 3” X 2” FL GREEN 300 PER ROLL PRICE GROUP 3 REV 1/07 50000-118 3/8” X 1.25” FL PINK 500 PER ROLL PRICE GROUP 1 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 MEDICAL RECORDS DATE:_________________ AGE:____G:_________P:___________AB:_________L:___________ B/P:______________ Wt:________________Ht:__________________ LMP:_____________ Contraception:___________________________ Allergies__________________________________________________ Surgeries:_________________________________________________ Medications:_______________________________________________ _______________________________________________ Tobacco Use:______________________________________________ Reason for Visit:____________________________________________ Prepped________________ 5705-05 2.5” x 7” WHITE W/BLK PRINT 250 PER ROLL PRICE GROUP 5 Scanned________________ Indexed________________ QA Check______________ IMPORTANT! This patient is under court order, not to be released until provisions of the court order have been fulfilled. Destroy________________ SY400-K 2.5" X 2.5" Fl. Green 250 PER ROLL PRICE GROUP 3 11200-14 4” x 3” FL YELLOW 300 PER ROLL PRICE GROUP 5 REV 1/07 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 MEDICAL RECORDS Multidisciplinary Rounds __________________ ___________ PATIENT NAME DATE Multidisciplinary Rounds were conducted for the above named patient during which the following areas were discussed: Treatment Plan Change in Condition Patient Education Restraints Advance Directives DNR Status Discharge Plan Spiritual Needs Functional Status Nutritional Status Psychosocial Status Other ___________________________________ ___________________________________ ___________________________________ Estimated date of discharge transfer is______or, unknown Potential Referral to Home Health Patient Rep Cardiac Rehab Not applicable PT/OT/Speech Social Services Chaplain Dietary Respiratory Care Other_______________________________________________ Documented by_________________________________________ 9000-43 4” x 3” 300 PER ROLL PRICE GROUP 5 REV 1/07 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 FILING LABELS NF310-RED NF311-GRAY NF312-BLUE NF313-ORANGE NF314-PURPLE NF315-BLACK NF316-YELLOW NF317-BROWN NF318-PINK NF319-GREEN 00 * ALL OF THE ABOVE ARE AMES COMPATIBLE 07 07 2007 YEAR LABELS AVAILABLE IN: PEACH BROWN TEAL/LIME GRAY RED BLACK PURPLE 1 7/8" x 1 7/8" 07 07 3/4" x 1 1/2" 2 0 0 7 11-060 REV 1/07 2 0 0 7 2 0 2 0 0 7 11-095 0 7 07 07 1/2" x 1" Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 M M 5720-57 1.5” X .5” 500 PER ROLL PRICE GROUP 2 FILING LABELS FFP400-L YELLOW FFP401-L BLUE FFP402-L PINK FFP403-L PURPLE FFP404-L ORANGE FFP405-L BROWN FFP406-L GREEN FFP407-L GRAY FFP408-L RED FFP409-L BLACK 00 2 X 1 1/2 * ALL OF THE ABOVE ARE SMEAD COMPATIBLE 67340 YELLOW 67341 BLUE 67342 PINK 67343 PURPLE 67344 ORANGE 67345 BROWN 67346 GREEN 67347 GRAY 67348 RED 67349 BLACK 00 1 X 1 1/4 * ALL OF THE ABOVE ARE SMEAD COMPATIBLE 2007 YEAR LABELS 07 07 1.75 X ½ 2006 YELLOW Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 FILING LABELS 67340 YELLOW 67341 BLUE 67342 PINK 67343 PURPLE 67344 ORANGE 67345 BROWN 67346 GREEN 67347 GRAY 67348 RED 67349 BLACK 00 1 X 1 1/4 * ALL OF THE ABOVE ARE SMEAD COMPATIBLE 04 04 06 06 3/4" x 1 1/2" RS11-090-06 YELLOW RS11-090-05 FL PINK RS11-090-04 GREEN RE11-090-03 PURPLE RS11-090-02 RED RS11-090-01 BLACK RS11-090-00 BLUE RS11-090-99 ORANGE Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 NURSING LABELS I.V. SET--________HOURS ONLY WRAP AROUND IV TUBING IV404-K IV405-K IV414-K IV415-K RN initial START--date/hr. DISCARD--date/hr. 24 HOURS ONLY 48 HOURS ONLY 72 HOURS ONLY 96 HOURS ONLY IV406-K ROLL OF 300 I.V. TUBING CHANGED WRAP AROUND IV TUBING Date____________________ Hr._______ By________________________________ IV407-K ROLL OF 300 48 HOUR CHANGE 48 HOUR CHANGE DATE _____________ TIME______________ CM308-K CM311-K CM310-K DATE _____________ TIME______________ RN. INITIAL________ 24 HOURS CHANGE 72 HOURS CHANGE __ HOURS CHANGE CM309-K ROLL OF 300 IV103-K IV244-K IV265-K IV201-K IV201-KCY I.V. SET - 24 Hours Only RN initial START - date/hr. DISCARD - date/hr. 48 HOURS ONLY 72 HOURS ONLY 96 HOURS ONLY __ HOURS ONLY 24 HOURS ONLY (YLW) IV101 ROLL OF 420 CHANGE SUNDAY CHANGE SUNDAY DATE _____________ TIME______________ #________ DATE _____________ TIME______________ RN. INITIAL________ CM302-K CM303-K CM304-K CM305-K CM306-K CM307-K CHANGE MONDAY CHANGE TUESDAY CHANGE WEDNESDAY CHANGE THURSDAY CHANGE FRIDAY CHANGE SATURDAY CM301-K ROLL OF 300 Revised: 4/04 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 FLUORESCENT ORANGE FLUORESCENT GREEN FLUORESCENT YELLOW LIGHT BLUE TAN FLUORESCENT RED NURSING LABELS DRWHT2 ROLL OF 200 ROOM NO. PATIENT DOCTOR DRWHT1 ROLL OF 200 DR3602 GREEN DRYEL2 YELLOW DR1962 PINK DR1852 RED DR2982 BLUE DR1512 ORANGE DR4292 GRAY DR5272 LAVENDER DR2182 ROSE DR2902 SKY BLUE DR3672 LIME DR3252 AQUA DR4652 BROWN/COPPER DR1412 TAN DR1092 GOLDENROD DR2562 VIOLET DRSIL2 SILVER DR1622 SALMON/PEACH DR3902 CHARTREUSE DR3601 GREEN DRYEL1 YELLOW DR1961 PINK DR1851 RED DR2981 BLUE DR1511 ORANGE DR4291 GRAY DR5271 LAVENDER DR2181 ROSE DR2901 SKY BLUE DR3671 LIME DR3251 AQUA DR4651 BROWN/COPPER DR1411 TAN DR1091 GOLDENROD DR2561 VIOLET DRSIL1 SILVER DR1621 SALMON/PEACH DR3901 CHARTREUSE Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 NURSING LABELS PATIENT DOCTOR WTPI-1 200 PER PACK SPINE CARD Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 WTPI-2 WTPI-3 WTPI-4 WTPI-5 WTPI-6 WTPI-7 WTPI-8 WTPI-9 WTPI-10 WTPI-11 WTPI-13 WTPI-15 WTPI-16 WTPI-17 WTPI-19 YELLOW GREEN PINK RED SKY BLUE ORANGE GRAY LAVENDER LIGHT SCARLET MEDIUM BLUE AQUA TAN PEACH VIOLET SHELL NURSING LABELS ROOM NO. ALLERGIC 1646-01 ROLL OF 200 1646-06 ROLL OF 200 Rm. No. Patient Doctor W002K 1/2" X 500" PRINTED TAPE 2WZ5C 1/2" X 500" BLANK TAPE Y002K G002K 196K R002K O002K B002K 141K 162K 465K 218K 256K 527K 429K 367K 325K YELLOW GREEN PINK RED ORANGE BLUE TAN SALMON/PEACH COPPER/BROWN ROSE VIOLET LAVENDER GRAY LIME AQUA 2YZ5C 2GZ5C 196Z5C 2RZ5C 2OZ5C 2BZ5C 141Z5C 162Z5C 465Z5C 218Z5C 256Z5C 527Z5C 429Z5C 367Z5C 325Z5C YELLOW GREEN PINK RED ORANGE BLUE TAN SALMON/PEACH COPPER/BROWN ROSE VIOLET LAVENDER GRAY LIME AQUA Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 NURSING LABELS 2WZ1C 1" X 500" BLANK TAPE NOTHING BY MOUTH 2YZ1C 2GZ1C 196Z1C 2RZ1C 2OZ1C 2BZ1C 141Z1C 162Z1C 465Z1C 218Z1C 256Z1C 527Z1C 429Z1C 367Z1C 325Z1C YELLOW GREEN PINK RED ORANGE BLUE TAN SALMON/PEACH COPPER/BROWN ROSE VIOLET LAVENDER GRAY LIME AQUA W526K 1" X 500" TAPE HISTORY & PHYSICAL NEEDED Y526K 1" X 500" TAPE ALLERGIC: Revised: 4/04 W505R 1" X 500" TAPE Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 NURSING LABELS SURGERY G752BK 3/4" X 500" TAPE ISOLATION W900RC 2" X 500" TAPE ATTENTION: SN-6 1" X 500" TAPE Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 NURSING LABELS ALLERGIC TO: AMNIOINFUSION BAG HN303-KO 1" X 3" 300 PER ROLL PRICE GROUP 3 The Healthcare Decision-maker is: NameRelationship- 2000-70 3" X 4" 300 PER ROLL PRICE GROUP 5 15275-26 1.5" x 3" 300 PER ROLL PRICE GROUP 3 The presence of any one of the following criteria will require a referral for more intensive intervention. Nutritional & Rehab screening referrals will be provided to the pt through the distribution of a brochure, telephone number and self referral. Abuse screening - Social Services x7564 No referral needed 1. Physical signs of neglect 2. Domestic violence 3. Suspicion of psychological, fiduciary, physical abuse, sexual abuse 4. No/limited prenatal care 5. + tox screen Infant/Mother ADVANCE DIRECTIVE ____________ Nutritional Screening - Dietary x3610 No referral needed 1. Unintentional weight loss > 10 lbs in 3 wks 2. Renal insufficiency Hepatic disease/Dx malnutrition 3. Gestational/first onset diabetes/diabetes out of control. 4. > age 55 exhibiting 1 or > prior risk factors 5. Significant food allergies 6. Hypermesis 7. Pregnancy w/lactation from previous pregnancy 8. Preg wt gain <8 lbs or>45 lbs at >at 35 wks 9. Other concerns __________________________ Brochure given MR297-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 ______MG EQUALS 13300-120 2" X 3" 300 PER ROLL PRICE GROUP 3 CUSTOM PER FACILITY Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 ______ML 8925-30 1" X 1" 980 PER ROLL PRICE GROUP 2 NURSING LABELS SUICIDE REMINDER! PRECAUTIONS Physician signature, date, and time are required on all verbal orders within 48 hours. SY260-K 7/8" X 2.25" 400 PER ROLL PRICE GROUP 2 DAY CERTIFICATION INVOLUNTARY 14 Thank you in advance for your assistance in this very important process. BEGAN____________ EXPIRES___________ SY204-K 1" X 2.5" 300 PER ROLL PRICE GROUP 2 15270-60 3" x 4" 300 PER ROLL PRICE GROUP 4 ALLERGIC TO: .......................... MEDICATION ADDED TO I.V. __________ HH215-K 1" X 3" 300 PER ROLL PRICE GROUP 3 ________________ __________________ Time Date Drug By Quantity _______________________________ NAME_______________________ _______________________________ _______________________________ ____________________________ Expires: Date ________Time______________ Rm. No._________Date________ HH207-K 2.5" X 2.5" 250 PER ROLL PRICE GROUP 3 LS106-K 7/8" X 2.25" 400 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 NURSING LABELS Privacy Notice UNOS _____________ ABO_______________ Request for Amendment Disclosures Request for Confidential Information 10850-UNOS 1.5" X 4" 300 PER ROLL PRICE GROUP 3 Request for Restrictions _____________________ RESTRICT FLUIDS __________CC/24 hr _____________________ 7025-33 3" x 4" 1000 PER ROLL PRICE GROUP 4 SKIN TEST- type____________ initial DAYS ___________CC PMS ____________CC MOCS___________CC location______________ TO BE READ: date time ____48 hrs_____induration (mm)___NEG_____ HN494-K 4" X 3" 300 PER ROLL PRICE GROUP 5 ____48 hrs_____induration (mm)___NEG_____ PC271-K 3" X 2" 300 PER ROLL PRICE GROUP 4 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 NURSING LABELS CHEMOTHERAPY PT.________________________RM.__________________ DRUG____________________________________________ AMOUNT_________________________________________ ADDED BY________________________________________ DATE____________________________________________ USE BEFORE______________________________________ STORAGE________________________________________ 6700-24 1" X 2.5" 150 PER ROLL PRICE GROUP 2 FALL PRECAUTIONS HN137-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 EPIDURAL * USE ONLY * HN758-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 GENERAL 24-HOUR URINE COLLECTION No Preservative added Keep Refrigerated UC200-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 ALLERGIES/UNTOWARD REACTIONS ______________________ ALLERGIC MC029-K 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 PRE-OP HT123-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 ______________________ ______________________ ______________________ ______________________ ______________________ NL2261 2.5" X 2.5" 250 PER ROLL PRICE GROUP 3 10 DAYS OLD: ________ 14900-18 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 DISCARD____days after DATE: 13300-100 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 ALLERGIES ______________ ______________ ______________ ______________ ______________ ______________ ALLERGIC TO: MINOR MR204-K 2.5" X 2.5" 250 PER ROLL PRICE GROUP3 Rec'd________________ Init. 13810-05 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 Revised: 4/04 CR014-K 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 Opened______________ Init. CL239-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 NURSING LABELS TCU 9100-122 1" X 2 1/2" 300 PER ROLL PRICE GROUP 3 ARU 9100-123 1" X 2 1/2" 300 PER ROLL PRICE GROUP 3 Breast Milk Fresh/Frozen Expires 9100-74 7/8" x 1 5/8" 500 PER ROLL PRICE GROUP 2 OBS 10850-OBS 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 EPIDURAL/SPINAL NARCOTIC CALL ANESTHESIOLOGIST CONCERNING ANY PAIN CONTROL PROBLEMS UNTIL: (DATE):_________(TIME):________ Physician:_____________________ Beeper#:______________________ Home#:_______________________ MRSA Operating Room#: 6300-07 2.5" x 2.5" 250 PER ROLL PRICE GROUP 3 15270-39 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 FOR EPIDURAL ADMINISTRATION ONLY DISCHARGE PLANNING UPDATE ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ FP735-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 ___________________________ ___________________________ ___________________________ DO NOT REMOVE ___________________________ Anti-Syphon Valve WEIGH DAILY HH303-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 50007-02 7/8" x 1 5/8" 500 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. Revised: 4/04 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 SS102-K 2.5" x 2.5" 250 PER ROLL PRICE GROUP 3 NURSING LABELS I.V. SITE NEEDLE TYPE:_________________ INSERTED: DATE_______________ TIME_______________ NURSE/MD____________________ DR. NAME:___________ PT. NAME:____________ DATE:________________ IV223-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 LOANER:_____________ _____OF_____ IV SITE CARE q_____Hr(s) DRESSED DATE___________ REDRESSED DATE_________ __________________NURSE IV217-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 CAUTION Injected with radioisotope. Urine, Feces, Vomitus Radionuclide free on______ 13800-144 2" X 3" 300 PER ROLL PRICE GROUP 3 CAUTION: Central Line Administration ONLY 6700-58 1" x 3" 300 PER ROLL PRICE GROUP 3 IV217-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 Warm each Intermate to room temperature for 4 hours prior to infusion. POST OP CARDIAC PT-Conc. KCL ready to be INFUSED CENTRALLY 3500-10P 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 Revised: 4/04 3500-36 1" x 3" 300 PER ROLL PRICE GROUP 3 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 NURSING LABELS NUTRITION UPDATE no G.I. complaints reported diarrhea ____________________________ nausea/vomiting constipation ____________________________ Appetite: good fair poor improving NPCR: <1.0 >1.0 Wt. status: stable loss/gain______kg_____________________________________ Visceral protein status: adequate depleted(mild/moderate/severe)_____________ Labs indicative of: hyperphosphatemia elevated CaxP product hyperparathyroidism hyperkalemia hyper/hypocalcemia poor BS control CO2-metabolic acidemia nutrition labs WNL for dialysis __________________________________________ Fluid control: acceptable excessive gains_______________________________ Educated/Encouraged compliance on: K phos protein fluid binders Comments:_______________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Plan/Goals/Recommendations: follow-up diet education as needed reviewed monthly labs _________________________________ monitor nutritional status/(KTV)PCR Signature:________________________ < T 13800-159 4" x 6" 100 PER ROLL PRICE GROUP 5 MEDICAL CAUTION OB 9100-128 1" X 2.5" 300 PER ROLL PRICE GROUP 2 Revised: 4/04 310095-01 1.75" X 2.5" 500 PER ROLL PRICE GROUP 3 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 NURSING LABELS STANDING LATEX PRECAUTIONS 6000-24 1” X 3” 300 PER ROLL PRICE GROUP 3 WEIGHT BEARING HN494-K 4" X 3" 300 PER ROLL PRICE GROUP 5 ADVANCE DIRECTIVES 6000-23 1” X 3” 300 PER ROLL PRICE GROUP 3 RESISTANT MICROORGANISM STRICT ATTENTION TO GOOD HANDWASHING TECHNIQUE ESSENTIAL TO PREVENT CROSS INFECTION. 1646-23 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 PC328-K 1” X 3” 300 PER ROLL PRICE GROUP 3 HISTORY & PHYSICAL D.N.R. 1646-23 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 Revised: 8/04 9100-132 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 NURSING LABELS PATIENT RESTRAINT ORDERS Information below must be included in all orders, “PRN ORDERS ARE NOT ACCEPTABLE.” Date:___________________________Time:_____________________________ RETURN TO EMERGENCY ROOM Restrain patient for up to 24 hours using (may not exceed 24 hours): _______Vest (posey) restraint _______ Soft ankle restraint _______Soft wrist restraints ER201-KR 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 _______ Other (specify) _________________________________ _________________________________________________________________________________ Purpose: ______Safety (nursing document every 2 hours). ______Prevention of patient interrupting treatment such as dislodging IV, feeding tube, vent (Nursing document every 2 hours). ______Protection of patient from harming self or others (Nursing document every 15 minutes). Telephone order: ______________________________________RN/_____________________________________MD Physician Signature:_______________________________________________________________ RETURN TO L&D F5010 3” X 4” 300 PER ROLL PRICE GROUP 4 Revised: 8/04 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 5002 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 I.V. LABELS I.V. SET--________HOURS ONLY WRAP AROUND IV TUBING RN initial START--date/hr. IV404-K IV405-K IV414-K IV415-K 24 HOURS ONLY 48 HOURS ONLY 72 HOURS ONLY 96 HOURS ONLY FLUORESCENT PINK FLUORESCENT YELLOW FLUORESCENT ORANGE FLUORESCENT RED DISCARD--date/hr. IV406-K ROLL OF 300 I.V. TUBING CHANGED WRAP AROUND IV TUBING I.V. SET-__________Hours Only WRAP AROUND IV TUBING Date____________________ Hr._______ By________________________________ By________________________________ IV407-K ROLL OF 300 48 HOUR CHANGE IV408-K ROLL OF 300 48 HOUR CHANGE DATE _____________ TIME______________ Date____________________ Hr._______ DATE _____________ TIME______________ RN. INITIAL________ CM308-K CM311-K CM310-K 24 HOURS CHANGE FLUORESCENT PINK 48 HOURS CHANGE FLUORESCENT YELLOW __ HOURS CHANGE FLUORESCENT ORANGE CM309-K ROLL OF 300 I.V. SET - 24 Hours Only RN initial START - date/hr. IV103-K IV244-K IV201-K 48 HOURS ONLY 72 HOURS ONLY __ HOURS ONLY DISCARD - date/hr. IV101-K ROLL OF 420 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 FLUORESCENT YELLOW FLUORESCENT ORANGE FLUORESCENT GREEN I.V. LABELS CHANGE SUNDAY CM302-K CM303-K CM304-K CM305-K CM306-K CM307-K CHANGE SUNDAY DATE _____________ TIME______________ #________ DATE _____________ TIME______________ RN. INITIAL________ CHANGE MONDAY CHANGE TUESDAY CHANGE WEDNESDAY CHANGE THURSDAY CHANGE FRIDAY CHANGE SATURDAY ORANGE GREEN YELLOW LIGHT BLUE TAN RED CARDIAZEM 10850-90 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 REVISED 8/04 DOPAMINE EPINEPHRINE EPINEPHRINE 10850-93 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 FENTANYL FENTANYL 10850-95 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 LABETALOL LABETALOL 10850-97 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 ------------------------- ------------------------- ------------------------- 10850-92 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 10850-94 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 LEVOPHED LEVOPHED 10850-98 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 LIDOCAINE ------------------------- DOPAMINE ESMOLOL LIDOCAINE 10850-99 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 MORPHINE ------------------------- CARDIAZEM ------------------------- 10850-89 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 10850-91 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 ESMOLOL ------------------------- AMIODARONE DOBUTAMINE ------------------------- AMIODARONE ------------------------- 10850-88 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 DOBUTAMINE ------------------------- AMINOPHYLLINE ------------------------- AMINOPHYLLINE ------------------------- CM301-K ROLL OF 300 MORPHINE 10850-100 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 NIPRIDE 10850-103 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 NORCURON WRAP AROUND IV TUBING -------------------------- 10850-102 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 NORCURON 10850-104 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 PROPOFOL 10850-105 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 PITRESSIN PITRESSIN VERSED 10850-106 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 CATHETER IN PLACE Date_____________Time____________ Type____________________________ Site______________________________ CU221-K 1” X 3” 300 PER ROLL CAUTION CENTRAL LINE ONLY 3840-30 1” X 2.5” RED 300 PER ROLL REVISED 9/06 15270-92 7/8” x 2.25” Fl. Green 300 PER ROLL PRICE GROUP 3l CHANGED CHANGED DATE:________ DATE:__________ DUE:_________ DUE:___________ RN INITIAL:____ RN INITIAL:______ 15272-02 1” X 2.5” FL PINK 300 PER ROLL Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 PROPOFOL 10850-107 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 TROUGH LEVELS ORDERED Contact lab prior to next scheduled infusion. ------------------------- PITOCIN ------------------------- NIPRIDE ------------------------- 10850-101 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 PITOCIN ------------------------- NITROGLYCERIN NITROGLYCERIN ------------------------- ------------------------- NEOSYNEPHRINE NEOSYNEPHRINE ------------------------- ------------------------- I.V. LABELS VERSED 10850-108 7/8” X 1 5/8” 500 PER ROLL PRICE GROUP 2 I.V. LABELS LINE INSERTION DATE _______________________________ 3500-67 7/8” X 2.25” FL PINK 420 PER ROLL PRICE GROUP 2 REV 9/06 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 EPIDURAL EPIDURAL FEMORAL NERVE BLOCK FEMORAL NERVE BLOCK FL YELLOW BLACK INK INTRAPERITONEAL INTRAPERITONEAL WHITE WITH BLUE INK HYPERALIMENTATION HYPERALIMENTATION FL PINK WITH BLACK INK HEMODIALYSIS HEMODIALYSIS CATHETER CATHETER BLANK WHITE LABEL CENTRAL LINE CENTRAL LINE PERITONEAL DIALYSIS CATHETER PERITONEAL DIALYSIS CATHETER AQUA BLUE BLACK INK GASTRIC TUBE GASTRIC TUBE PATIENT SERVICES Patient's condition prevented the admitting office from getting this form signed on admission. Please ask patient to sign as soon as possible. Return copies to Admitting Office UTILIZATION REVIEW REVIEW DATE_____________ DOCTOR_________________ Average Medicare LOS______ Document in Progress Notes: AD211-K 1" X 3" 3OO PER ROLL PRICE GROUP 3 FORMS NEED SIGNATURE Reason for continued stay Reason for inpatient work up Treatment plan Anticipated discharge date --------------------------------------------------------------------------------- UT138-K 2.5” X 2.5” 250 PER ROLL PRICE GROUP 3 AD209-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 A MEMO FROM NO INSURANCE CARD AVAILABLE AT TIME OF REGISTRATION UTILIZATION REVIEW: AD246-K 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 JEHOVAH'S WITNESS UT152-K 2.5” X 2.5” 250 PER ROLL PRICE GROUP 3 OB252-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 Revised: 8/04 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 PATIENT SERVICES PLEASE SEND FAMILY TO ADMISSION OFFICE YOUR INSURANCE COMPANY HAS PAID ITS SHARE OF YOUR BILL.. This statementis for the amount payable directly by you. AD232-K 7/8” X 2.25” FL YELLOW 420 PER ROLL WE ACCEPT VISA NOSOTROS ACEPTAMOS AND MASTERCARD VISA Y MASTERCARD SU COMPANIA DE SEGURO MEDICO A PAGADO LA PARTE DE LA CUENTA.. BS105-K 1” X 2.5” YELLOW 300 PER ROLL BS101-K 7/8” X 2.25” FL GREEN 420 PER ROLL MEDICARE has paid its share of your bill. This statement is for the amount payable directly by you to us. Thank You MEDICARE A pagado su porcion de su cuenta. Este estado de cuenta es por la cantidad pagable directamente por usted a nosotros. Gracias BS106-K 7/8” X 2.25” FL PINK 420 PER ROLL Your Insurance Company has not paid this claim because: Deductible Taken Non-covered Service Insurance Cancelled Requested Information Not Received Please remit prompt payment MC795-K 1” X 3” FL YELLOW 300 PER ROLL REV 9/06 Este estado de cuenta es por la cantidad pagable directamente por usted. Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 VISITOR PASSES VISITORS PASS Name______________________________ Date______________Room No._________ THANKS FOR NOT SMOKING GENERIC VISITOR PASS BR201 BR202 BR203 BR204 BR205 BR206 BR207 BLUE ORANGE GREEN BROWN RED BLACK PURPLE BR205 2" X 3" 500 PER ROLL PRICE GROUP 3 COASTAL COMMUNITIES HOSPITAL VISITORS PASS SATURDAY Name:__________________________ Location:_____________Date:_______ CONTRACTOR PASS _________________ NAME: _________________ DATE: AUTHORIZATION: _________________ St. Mary Medical Center 14295-09 2" x 3" 500 PER ROLL PRICE GROUP 3 3840-20 2" x 3" 500 PER ROLL PRICE GROUP 3 *ALL VISITOR PASSES CAN BE CUSTOMIZED PER FACILITY Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 VISITOR PASSES KINDRED ARROWHEAD REGIONAL MEDICAL CENTER NAME:_______________________ CO. NAME:___________________ DATE:_______________________ AREA VISITED:________________ Name___________________________________ VISITOR / VENDOR VISITORS PASS _______________ Date_________________Room No.__________ THANKS FOR NOT SMOKING 10850-32 2" X 3" 500 PER ROLL PRICE GROUP 3 15275-08 2" X 3" 500 PER ROLL PRICE GROUP 3 Glendale Memorial Hospital and Health Center CHW BUSINESS REPRESENTATIVE Visitor Pass Room:_______Date:______ Please wear this pass at all times. Visiting hours are 11am to 8pm. Please, only 2 visitors per patient. Check with the nurse for visitors under 14. Date_________________________________ Destination___________________________ _____________________________________________________________ THANKS FOR NOT SMOKING 5720-15 2" x 3" 500 PER ROLL PRICE GROUP 3 Revised: 4/04 BR101-K 2" x 3" 500 PER ROLL PRICE GROUP 3 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 VISITOR PASSES VISITOR PASS DESTINATION________________________ NAME OF VISITOR____________________________ DATE______________________________ 3840-26 3” X 2” 300 PER ROLL PRICE GROUP 3 KINDRED EMPLOYEE NAME:________________ DEPT:_________________ DATE:_________________ 3840-26 3” X 2” 300 PER ROLL PRICE GROUP 3 Revised: 8/04 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 PHARMACY LABELS IV SET-72 HOURS ONLY ________________________________ RN initial ________________________________________ START-Date/Hr. ________________________________________ Discard Date/Hr. ________________________________________ IV SET-24 SET-72 HOURS ONLY RN initial ________________________________________ START-Date/Hr. ________________________________________ Discard Date/Hr. ________________________________________ ----------------------- IV101 1" X 2.5" 300 PER ROLL PRICE GROUP 2 Time_____________ HYDROMORPHONE (DILAUDID) 9100-125 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 mg/ml ________________________________ Date______________ AM717-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 DEMEROL IV4325 1" X 2.5" 300 PER ROLL PRICE GROUP 2 CENTRAL VENOUS LINE VERSED __________Mg/cc AM759-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 By__________________ (ATIVAN) DEMEROL 50 MGM/CC 4325-41 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 FENTANYL ___________mg/ml CENTRAL VENOUS LINE LORAZEPAM 4325-40 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 9100-126 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 Calcium Chloride Drip (Central line only. Do not mix with TPN, Sodium Bicarbonate or Phosphate salts.) HEPARIN 3500-63 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 Units/CC LI204-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 AM119-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 Alprostadil (PGE) 3500-04 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 0800 DOSE EPIDURAL 9100-124 1" X 1" 500 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 50000-13 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 TRASYLOL 14295-14 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 REVISED 9/05 PHARMACY LABELS PARENTERAL SOLUTIONS 72 Patient______________________Room_______ HOUR INVOLUNTARY HOLD BEGAN_____________ EXPIRES____________ Bag/Bottle No._____Date______Time_________ SY203-K 1" X 2.5" 300 PER ROLL PRICE GROUP 2 Solution: Medications Added: WARMER Rate________cc/hr______gtts/min. By_______ Exp. Date________________________________ DATE IN_____________________________ DO NOT LEAVE IN WARMER BEYOND 72 HOURS DO NOT REWARM SOLUTION. 6950-14 1" X 3" 300 PER ROLL PRICE GROUP 3 PARENTERAL SOLUTIONS DATE:______________________TIME:_______________________ --------- IV501 3" X 4" 300 PER ROLL PRICE GROUP 4 I.V. SET-72 Hours Only START DATE________H.R.______ DISCARD DATE______H.R._____ R.N. NAME__________________ RM:______________NAME:________________________________ 10850-41 1" X 3" 1000 PER ROLL PRICE GROUP 3 RATE:____________________________________________________ 10840 3” X 2” LT BLUE PRICE GROUP 3 REVISED 9/06 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 PHARMACY LABELS DOPAMINE LIDOCAINE 14725-37 1" X 3" 300 PER ROLL PRICE GROUP 3 15270-47 1" X 3" 300 PER ROLL PRICE GROUP 3 DOPAMINE LIDOCAINE 10850-71 1" X 3" 300 PER ROLL PRICE GROUP 3 14725-39 1" X 3" 300 PER ROLL PRICE GROUP 3 INSULIN LIDOCAINE 14725-38 1" X 3" 300 PER ROLL PRICE GROUP 3 14725-39 1" X 3" 300 PER ROLL PRICE GROUP 3 INSULIN INSULIN CU-INSULIN 7/8" X 2.25" 300 PER ROLL PRICE GROUP 2 LIDOCAINE 9100-07 7/8" X 2.25" 300 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. REVISED 9/06 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 6375-22 1" X 2.5" 300 PER ROLL PRICE GROUP 2 PHARMACY LABELS NOTE: CONTAINS MORE THAN ONE DOSE ALLERGIES FP269-K 7/8" X 2.25" 300 PER ROLL PRICE GROUP 2 . NORMAL SALINE 13475-51 7/8" X 2.25" 300 PER ROLL PRICE GROUP 2 MR204-K 2.5" X 2.5" 300 PER ROLL PRICE GROUP 3 FIRST DRUG TO EXP___________________________ DATE NAME OF DRUG_______________________________ HEPARINIZED SALINE FLUSH (50ml) Concentration:1unit/1ml Prep by:______ Rx:_______ Date/Time Prep ___________ Lot#:___________ LOCK NUMBER________________________________ EXPIRES IN 24 HOURS / PLEASE REFIGERATE CHECK DONE ON______________________________ DATE INITIALS 2000-64 1.5" X 3" 300 PER ROLL PRICE GROUP 3 2000-57 1.5" X 3" 300 PER ROLL PRICE GROUP 3 *** 0800 DOSE *** PLEASE LEAVE MED IN BAGGIE UNTIL DOSE IS DUE. DATE FILLED:___________ CHECKED BY:___________ 9100-91 7/8" X 2.25" 300 PER ROLL PRICE GROUP 2 REVISED 9/05 2000-26 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 LOOK ALIKE/ SOUND ALIKE! 13800-145 1/2" X 1.5" 500 PER ROLL PRICE GROUP 2 PHARMACY LABELS I.V. RECORD PITOCIN Date __________________________ ____________________________UNITS Name _________________________ ADDED TO_______________________CC Room# _________ Bed ___________ Solution _______________________ TIME_________________BY____________ Med Added _____________________ _______________________________ OB312-K 2" X 3" 300 PER ROLL PRICE GROUP 3 _______________________________ _______________________________ Time Started ___________________ AGGRASTAT Gtts/Min. _______________________ Time Disc. ______________________ IVR1525 4" X 3" 250 PER ROLL PRICE GROUP 5 10850-171 1” X 2.5” FL GREEN PRICE GROUP 2 INTEGRILIN Crash Cart Check First Drug to Exp.___________________ Date Name of Drug ______________________ Lock Number_______________________ Check done on _______ _____________ 10850-170 1” X 2.5” FL GREEN PRICE GROUP 2 STAT HT116-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 Date DOSE = 1/2 TAB Initials FP304-K 1.5" X 3" 300 PER ROLL PRICE GROUP 3 13300-93 3/8 X 1.25" 500 PER ROLL PRICE GROUP 1 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 REVISED 9/06 PHARMACY LABELS PRE-MEDICATION REFRIGERATE 6375-26 7/8" X 2.25" 300 PER ROLL PRICE GROUP 2 7025-34 1” X 3” 300 PER ROLL PRICE GROUP 3 DO NOT __________________________ REFRIGERATE POTASSIUM ADDED 6375-26 7/8" X 2.25" 300 PER ROLL PRICE GROUP 2 FP745-K 1" X 2.5" 300 PER ROLL PRICE GROUP 2 PLEASE SAVE RETURN TO PHARMACY WHEN EMPTY POTASSIUM 9100-84 1" X 2.5" 300 PER ROLL PRICE GROUP 2 PH224-K 7/8" X 2.25" 300 PER ROLL PRICE GROUP 2 HEPARIN 25000 UNITS CONTAINS POTASSIUM CHLORIDE 13300-56 1" X 2.5" 300 PER ROLL PRICE GROUP 2 REVISED 9/06 IN 500 ML 15600-44 3" X 2" 500 PER ROLL PRICE GROUP 3 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 PHARMACY LABELS MEDICATION ADDED DRUG AMOUNT ADDED BY DATE HEPARIN 1000 UNITS TIME EXP. DATE IN 500 ML THIS LABEL MUST BE AFFIXED TO ALL INFUSION FLUIDS CONTAINING ADDITIONAL MEDICATION HH506-K 2.5" X 1.75" 500 PER ROLL PRICE GROUP 3 MEDICATION ADDED PATIENT DRUG 15600-43 2" X 3" 500 PER ROLL PRICE GROUP 3 RM. MEDICATION ADDED AMOUNT ADDED BY Drug_______________________________ Amount_____________________________ Added By____________________________ DATE START TIME EXP. DATE THIS LABEL MUST BE AFFIXED TO ALL INFUSIION FLUIDS CONTAINING ADDITIONAL MEDICATION. 10850-132 1” x 2.5” FL RED PRICE GROUP 2 N200-K 2.5" X 1.75" 500 PER ROLL PRICE GROUP 3 MEDICATION ADDED DRUG AMOUNT ADDED BY DATE EXP. DATE MEDICATION - ADDED PATIENT___________ ROOM NO._________________ DRUG TIME DATE_______________TIME_____________________ THIS LABEL MUST BE AFFIXED TO ALL INFUSION FLUIDS CONTAINING ADDITIONAL MEDICATION ADDED BY___________________________________ HH505-K 2" X 3" 300 PER ROLL PRICE GROUP 3 HH506-KY 2.5" X 1.75" 500 PER ROLL PRICE GROUP 3 REVISED 9/06 DOSAGE Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 PHARMACY LABELS VECURONIUM (Paralyzing agent, will cause respiratory arrest) POTASSIUM RIDER (0.4 mEq/ml-CENTRAL line only via syringe pump) 3500-30 1" x 3" 300 PER ROLL PRICE GROUP 3 3500-46 1" x 2.5" 300 PER ROLL PRICE GROUP 2 POTASSIUM RIDER (0.1 mEq/ml-for PERIPHERAL line) MAGNESIUM SULFATE 3500-47 1" x 3" 300 PER ROLL PRICE GROUP 3 3500-32 1" x 2.5" 300 PER ROLL PRICE GROUP 2 Propofol EPInephrine (Change tubing and syringe q24h) (avoid extravasation) 3500-59 7/8" x 2.25" 420 PER ROLL PRICE GROUP 2 3500-61 1" x 2.5" 300 PER ROLL PRICE GROUP 2 DILTIAZEM 6700-94 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 9100-63 1" x 2.5" 300 PER ROLL PRICE GROUP 2 REVISED 9/05 RECON W.___ML STERILE H2O CONC=_____MG/ML RECON DATE:___/___/___ EXP DATE:___/___/___ TX:____RX:____ Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 PHARMACY LABELS GENTAMICIN PHENYLEPHRINE 9100-72 1" X 2.5" 300 PER ROLL PRICE GROUP 2 9100-89 1" X 2.5" 300 PER ROLL PRICE GROUP 2 COLACE 50 mg 5 ml FLAGYL HOUSE SUPPLY 13300-103 7/8" x 2.25" 420 PER ROLL PRICE GROUP 2 9100-88 1" X 2.5" 300 PER ROLL PRICE GROUP 2 PHARMACY Medication to expire next:_______________ _____________________________________ Expires:______________________________ Checked by:___________Date:___________ KLONOPIN 13300-84 1" x 3" 300 PER ROLL PRICE GROUP 3 13300-153 7/8" x 2.25" 420 PER ROLL PRICE GROUP 2 Neonatal Heparin Flush Heparin 1 unit/ml 0.45%NS 6700-96 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 REVISED 9/05 DO NOT USE AFTER Date______________ FP128-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 1% NESCAINE 50000-12 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 1% LIDOCAINE 50000-11 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 PHARMACY LABELS OXYTOCIN 20 UNITS OXYTOCIN 20 UNITS D5 LR 1000 ML 0.9% Sodium Chloride 1000 ML Please Note Exp. Date Please Note Exp. Date 15600-47 2" x 3" 500 PER ROLL PRICE GROUP 3 15600-48 2" x 3" 500 PER ROLL PRICE GROUP 3 OXYTOCIN OXYTOCIN 20U/LITER 6955-01 1” X 3” 300 PER ROLL PRICE GROUP 3 9100-134 1” X 2.5 300 PER ROLL PRICE GROUP 2 FENTANYL FENTANYL 3500-06 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 10850-74 1” X 3” 300 PER ROLL PRICE GROUP 3 FENTANYL FENTANYL 15270-118 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 REVISED 1/07 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 4325-109 7/8" x 2.25" 420 PER ROLL PRICE GROUP 2 PHARMACY LABELS HEPARIN NITROGLYCERIN 15270-46 1" X 3" 300 PER ROLL PRICE GROUP 3 5720-49 1" X 3" 300 PER ROLL PRICE GROUP 3 HEPARIN NITROGLYCERIN 10850-75 1" X 3" 300 PER ROLL PRICE GROUP 3 10850-82 1" X 3" 300 PER ROLL PRICE GROUP 3 NITROGLYCERIN NITROGLYCERIN 100 MG DATE TIME 5720-46 2” X 3” 300 PER ROLL PRICE GROUP 3 REVISED 1/07 6375-14 1" X 2.5" 300 PER ROLL PRICE GROUP 2 SHAKE WELL BEFORE USING FP937-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 NOTE DOSAGE STRENGTH 13300-130 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 NOTE DOSAGE STRENGTH FP161-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 PHARMACY LABELS LEVOPHED EPINEPHRINE __MG __MG DATE TIME DATE 5720-51 2” X 3” 300 PER ROLL PRICE GROUP 3 5720-48 2” X 3” 300 PER ROLL PRICE GROUP 3 LEVOPHED EPINEPHRINE 5720-50 1” X 3” 300 PER ROLL PRICE GROUP 3 5720-45 1” X 3” 300 PER ROLL PRICE GROUP 3 LEVOPHED EPINEPHRINE 10850-77 1” X 3” 300 PER ROLL PRICE GROUP 3 10850-72 1” X 3” 300 PER ROLL PRICE GROUP 3 AMIODARONE AMIODARONE 10850-68 1” X 3” 300 PER ROLL PRICE GROUP 3 REVISED 9/05 TIME 9100-85 1" x 2.5" 300 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 PHARMACY LABELS HIGH STRENGTH MS 5 mg / ml CARDIAZEM 9100-44 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 10850-69 1” X 3” 300 PER ROLL PRICE GROUP 3 DOUBLE STRENGTH NIPRIDE FP270-K 7/8" X 2.25" 300 PER ROLL PRICE GROUP 2 10850-81 1” X 3” 300 PER ROLL PRICE GROUP 3 VERSED 10850-87 1” X 3” 300 PER ROLL PRICE GROUP 3 NOTE STRENGTH 15600-50 2” X 3: 300 PER ROLL PRICE GROUP 3 NORCURON WARNING: PARALYZING AGENT-CAUSES RESPIRATORY ARREST! 10850-83 1” X 3” 300 PER ROLL PRICE GROUP 3 REVISED 1/07 AM282-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 PHARMACY LABELS EXPIRED MEDICATION INCINERATE ONLY 5785-10 2.5” X 7” 140 PER ROLL PRICE GROUP 3 DOPAMINE PROTAMINE __MG DATE TIME 5720-54 2” X 3” 300 PER ROLL PRICE GROUP 3 500 MG DATE PHENYLEPHRINE TIME 5720-47 2” X 3” 300 PER ROLL PRICE GROUP 3 Mg/ml AM021-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 REVISED 9/05 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 PHARMACY LABELS CORDARONE PITOCIN ___ MG DATE 10850-84 1” X 3” 300 PER ROLL PRICE GROUP 3 TIME 5720-53 2” X 3” 300 PER ROLL PRICE GROUP 3 CORDARONE ETOMIDATE 5720-35 1” X 3” 300 PER ROLL PRICE GROUP 3 5720-52 1” X 3” 300 PER ROLL PRICE GROUP 3 ESMOLOL LABETALOL 10850-73 1” X 3” 300 PER ROLL PRICE GROUP 3 REVISED 9/05 10850-76 1” X 3” 300 PER ROLL PRICE GROUP 3 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 PHARMACY LABELS AMINOPHYLLINE NEOSYNEPHRINE 10850-67 1” X 3” 300 PER ROLL PRICE GROUP 3 10850-80 1” X 3” 300 PER ROLL PRICE GROUP 3 DOBUTAMINE PROPOFOL 10850-70 1” X 3” 300 PER ROLL PRICE GROUP 3 10850-86 1” X 3” 300 PER ROLL PRICE GROUP 3 MORPHINE PITRESSIN 10850-79 1” X 3” 300 PER ROLL PRICE GROUP 3 10850-85 1” X 3” 300 PER ROLL PRICE GROUP 3 ICU PAV EXPIRED Date______________ 15270-75 7/8” x 1 5/8” 500 PER ROLL PRICE GROUP 2 9100-133 1” X 2.5” 300 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 Revised 9/05 PHARMACY LABELS PLEASE PLACE ON FRONT OF CHART PATIENT__________________________ ROOM___________DATE____________ Potassium Chloride dilution 0.4meq/mL Insulin dilution 1 unit/mL 1meq/2.5mL D10W SBCH lot:_____________ 10mL SBCH lot:_____________ Date made:__________By:____________Ckd Date made:__________By:____________Ckd by:_________ by:_________ Expires:__________ Expires:__________ SINGLE DOSE VIAL MUST BE DISCARDED AFTER USE THE FOLLOWING MEDICATIONS BROUGHT BY PATIENT ARE BEING STORED IN THE PHARMACY: 4325-112 4325-111 1” X 3” 300 PER ROLL PRICE GROUP 3 CUSTOMIZED BY FACILITY _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ PLEASE RETURN THEM TO PATIENT ON DISCHARGE. Potassium Chloride dilution 0.4meq/mL 1meq/2.5mL D10W 10mL SBCH lot:_____________ Date made:__________By:____________Ckd by:_________ Expires:__________ SINGLE DOSE VIAL MUST BE DISCARDED AFTER USE 4325-111 1” X 3” 300 PER ROLL PRICE GROUP 3 CUSTOMIZED BY FACILITY FP400-K 4” X 3” 300 PER ROLL PRICE GROUP 5 Phenobarbital dilution 6.5mg/mL SBCH lot:_____________ Date made:__________By:____________Ckd by:_________ Expires:__________ Dexamethasone dilution 0.4mg/mL SBCH lot:_____________ Date made:__________By:____________Ckd by:_________ Expires:__________ SINGLE DOSE VIAL MUST BE DISCARDED AFTER USE SINGLE DOSE VIAL MUST BE DISCARDED AFTER USE 4325-114 1” X 3” 300 PER ROLL PRICE GROUP 3 CUSTOMIZED BY FACILITY 4325-113 1” X 3” 300 PER ROLL PRICE GROUP 3 CUSTOMIZED BY FACILITY Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 Revised 9/05 PHARMACY LABELS VASOPRESSIN PLASMANATE ALBUMIN 5% 5% INTERCHANGEABLE 9100-136 1" X 2.5" 300 PER ROLL PRICE GROUP 2 9100-150 7/8” X 2.25” FL RED 300 PER ROLL PRICE GROUP 2 MUST BE DILUTED ALBUMIN 25% 13300-57 1" X 2.5" 300 PER ROLL PRICE GROUP 2 9100-151 7/8” X 2.25” FL GREEN 300 PER ROLL PRICE GROUP 2 NON-STANDARD CONCENTRATION BREAK SEAL AND MIX BEFORE USE Date Vial Attached:___________________________ 3840-27 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 DOUBLE PORTION MB0042 7/8” X 2.25” FL PINK 300 PER ROLL PRICE GROUP 2 SODIUM BICARBONATE 15270-105 7/8” X 2.25” FL YELLOW 300 PER ROLL PRICE GROUP 2 9100-112 1" X 2.5" 300 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 Revised 9/06 PHARMACY LABELS LIDOCAINE 0.1MG/ML ADDED MORPHINE SULFATE 10850-181 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 DILAUDID 10850-183 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 MAGNESIUM SULFATE CU-MAGSUL 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 RCRA - WASTE Return Unused Portions To Pharmacy For Disposal 3500-74 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 13300-155 1” X 3” 300 PER ROLL PRICE GROUP 3 TPN FILTER HEPARIN 9100-97 1.5" X 4" 75 PER ROLL PRICE GROUP 3 15270-120 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 DATE OPENED: ____________ 15270-119 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 NOREPINEPHRINE EXPIRATION DATE__________ AM147-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 Laguna Coast Associates, Inc. Rev 1/07 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 9100-03 1" X 2.5" 300 PER ROLL PRICE GROUP 2 PHARMACY LABELS XANAX 13300-151 1” X 2.5” 300 PER ROLL PRICE GROUP 3 PITOCIN FENTANYL 13300-152 1” X 2.5” 300 PER ROLL PRICE GROUP 3 Qty_________________ 50007-04 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 6700-158 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 CU-PITOCIN 1” X 2.5” 300 PER ROLL PRICE GROUP 3 ATIVAN Date Opened_________ 9100-145 1” X 3” 300 PER ROLL PRICE GROUP 3 10% FORMALIN DRUG:____________ SB374-K 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. REV 1/07 MUTLI-DOSE VIAL Date Opened__________ Exp. Date_____________ Initial_________________ 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 10850-187 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 PHARMACY LABELS REAGENT:_______________________________ TITER, STRENGTH, OR CONCENTRATION:____ DATE PREPARED:_________________________ MADE BY:________________________________ PUT IN USE ON:___________________________ EXP. DATE:_______________________________ REFIG. TEMP. STORE AT ROOM TEMP. LOT NO._________________________________ VASOPRESSIN 20 UNITS/1 ML 5720-62 2” X 3” 300 PER ROLL PRICE GROUP 4 LR304-K 2.5” X 1.75” 300 PER ROLL PRICE GROUP 3 MEDICATION ADDED Date Anti-Depressant MEDICATION_____________________ PROCESSED REVERSE OSMOSIS H O Initial 2 _____R.O.________________ 4325-141 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 Observe the patient closely for significant side effects and report to the Physician. SIDE EFFECTS: Common - Sedation, Drowsiness, Dry Mouth, Blurred Vision, Urinary Retention, Tachycardia, Muscle Tremor, Agitation, Headache, Skin Rash, Photosensitivity(skin), Excess Weight Gain. DATE:___________________ TIME:___________________ LIMITED STABILITY SPECIAL ATTENTION FOR: Heart Disease, Glaucoma, Chronic Constipation, Seizure Disorder, Edema. KEEP IN REFRIGERATOR REMOVE 30 MINUTES PRIOR TO INFUSION INITIAL:_________________ 9100-157 7/8" X 1 5/8" 500 PER ROLL PRICE GROUP 2 L-2993 2” X 2” 250 PER ROLL PRICE GROUP 3 12100-02 2.5” X 2.5” 250 PER ROLL PRICE GROUP 3 PATIENT’S OWN MEDICATIONS Patient’s Cassette Pharmacy 6700-159 1” x 3” 300 PER ROLL PRICE GROUP 3 3500-72 1” x 3” 300 PER ROLL PRICE GROUP 3 Laguna Coast Associates, Inc. REV 1/07 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 PHARMACY LABELS BICARBONATE CONCENTRATE For Intrathecal Use Only (Place in Slip-tip Syringe) (No Preservatives) HCO 3 + R.O. MIXTURE DATE:_________________ TIME:_________________ PH:____________________ INITIAL:________________ *DISCARD AFTER 12 HRS 3500-69 7/8” x 2.25” 420 PER ROLL PRICE GROUP 2 Received:___________________ Parallel Checked: vs. Lot#:___________________ Date:______________________ Tech:______________________ 12100-03 2.5” X 2.5” 250 PER ROLL PRICE GROUP 3 15270-100 7/8” x 2.25” 420 PER ROLL PRICE GROUP 2 MAGNESIUM FENTANYL 9100-13 1” X 2.5” 300 PER ROLL PRICE GROUP 2 POTASSIUM CHLORIDE 11800-33 1” X 3” 300 PER ROLL PRICE GROUP 3 REV 1/07 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 13800-192 1” X 2.5” 300 PER ROLL PRICE GROUP 2 WILL COME OFF ROLL THIS WAY BACK SLIT TO REMOVE BACKING ON ONE SIDE U U U U U U U U U U U U U U U U U U U U UUU U U 4 x 3 LABEL PIGGY BACK SECOND LABEL IS 4 1/8 X3 1/8 DIRECT THERMAL BACKING IS 4 1/4 X 3 1/4 REPEAT IS 3 1/4 WITH BACK SLIT U U U U U U U U U U U U U U U U U U UUU SURGERY LABELS SUBLIMAZE VERSED ___________Mcg/cc AM129-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 AM717-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 FENTANYL AM175-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 AM750-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 ROBINUL KETAMINE AM154-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 DYSPHAGIA HD667-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 AM121-KC 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 ______ EPHEDRINE AM139-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 _ ___ __ _ __ _ __ NEOSTIGMINE ___ ___ ___ mg/ml ___ AM756-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 l ROMAZICON l l l mg/ml l l 4325-123 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 MORPHINE 6700-135 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 EPINEPHRINE 1:10.000/10CC 4325-126 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 FENTANYL 100 mcg/2ml 10 mg/ 1ccl 4325-125 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 GLYCOPYRROLATE Mg/ml VERSED mg/ml AM773-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 mcg/ml AM764-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 12000-120 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 Mg/ml MYOVIEW FENTANYL Midline mg/ml Mcg/cc ___________Mg/cc Midline ______________Mg/cc ATROPINE ________ FILTERED NM700-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 ANECTINE ________Mg/cc AM108-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 LIDOCAINE _______% AM075-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 AM744-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 ALFENTANIL mg/ml AM768-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 NORMAL SALINE 4325-124 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 NEOSYNEPHRINE AM125-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 NORMAL SALINE AM031-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP1 NORMAL SALINE AM141-KG 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 AM141-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 HEPARIN FLUSH DEMEROL ____________UNITS IV111-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 mg/ml AM759-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 Rev 9/06 SURGERY LABELS CABG Ht_____Wt______ BP on both Arms _______________ Antibiotics in OR (1)_____________ TRANSPLANT (2)_____________ 9100-120 2.5" x 2.5" 250 PER ROLL PRICE GROUP 3 13800-158 3" X 4" 300 PER ROLL PRICE GROUP 4 EYE CENTER DATE RECEIVED_____________________ 4325-09 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 VP-SHUNT CART DO NOT USE THIS LOT NUMBER 13800-191 1” X 3” 300 PER ROLL PRICE GROUP 3 Revised: 1/07 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 LR142-K 1.5" X 3" 300 PER ROLL PRICE GROUP 3 SURGERY LABELS * EPIDURAL USE ONLY OPEN HEART * HN758-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 DIFFICULT INTUBATION SAVE 502B 1 1/8" X 1 3/4" 300 PER ROLL PRICE GROUP 5 10850-112 2.5” X 1.75” 500 PER ROLL PRICE GROUP 3 Duramorph CONTACT ANESTHESIA FOR EXTUBATION Administered 10850-43 1.5" X 3" 300 PER ROLL PRICE GROUP 3 + Date:_____Time:___ Follow anesthesia orders for narcotic administration 1st 24 hours. SPINE Room 15 13800-189 1.5" X 3" 300 PER ROLL PRICE GROUP 3 13800-185 2.5” x 2.5” FL PINK 250 PER ROLL Arterial Arterial IMPLANT Venous Venous RUN WITH BIOLOGICAL TEST 10850-168 7/8" X 2.25" 300 PER ROLL PRICE GROUP 2 Revised: 1/07 CS082-K 7/8" X 2.25" 400 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 10850-169 7/8" X 2.25" 300 PER ROLL PRICE GROUP 2 SURGERY LABELS TRAUMA TEAM TRAUMA CAPTAIN Laguna Coast Associates, Inc. REV 1/07 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 10850-162 4” X 6” 100 PER ROLL PRICE GROUP 5 10850-161 4” X 6” 100 PER ROLL PRICE GROUP 5 RESPIRATORY THERAPY RESPIRATORY CARE DEPT. RESPIRATORY CARE DEPARTMENT ASSEMBLED AND CHECKED EVALUATION OF RESPIRATORY THERAPY By:_______________________________ DATE:________ PATIENT:________________________________________ROOM:_______ Date:_____________________________ Patient has been on_________________________for the past_______days ______________________________ RT042-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 Please Check for Evaluation of Respiratory Therapy Breath Sounds Improving Atelectasis Improving or Absent Sputum Mobilization Improving Infection Clearing Chest X-ray Improving Arterial Oxygenation Improving Other_____________________________________________________ ____________________________________________________________ Do you wish to: Continue Therapy as Ordered Change Therapy as Ordered Discontinue Therapy RESPIRATORY CARE DEPT. RETURN TO RESPIRATORY CARE Physician_____________________________________Date___________ RT009-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 RJ426-K 3" X 4" 300 PER ROLL PRICE GROUP 4 RESPIRATORY CARE DEPT. EMERGENCY EQUIPMENT BREAK SEAL WHEN NEEDED NOTIFY RESPIRATORY CARE WHEN USED Checked by:________________Date______ RESPIRATORY THERAPY DEPT. Patient has been receiving the following Therapy for the past (3) day Do you wish to: Continue Therapy as Ordered Change Therapy as Ordered Discontinue Therapy as Ordered Physician__________________________Date______________ 11200-12 1" x 3" 300 PER ROLL PRICE GROUP 3 RT502-K 3" X 4" 300 PER ROLL PRICE GROUP 4 Revised: 8/04 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 RESPIRATORY THERAPY RESPIRATORY THERAPY THREE DAY FOLLOW-UP ASSESSMENT/ORDER RENEWAL VENTILATOR CHECKLIST RESPIRATORY MODALITY____________________________________ DATE STARTED/RENEWED__________________________________________ DOCTOR: THE FOLLOWING ASSESSMNET OF THERAPY HAS BEEN MADE BY THE THERAPIST TREATING YOUR PATIENT VENT. I.D.#_______________ __________________________ IMPROVED WORSENED NO CHANGE MOBILIZATION OF SECRETIONS CXR ATELECTASIS ALVEOLAR OXYGENATION BREATH SOUNDS PEAK FLOWS SUGGESTION FOR THERAPY MODIFICATION:__________________________ THERAPIST SIGNATURE/DATE_________________________________________ ___________________________________________________________________ PHYSICIAN ORDER (SIGNING THIS STICKER SERVES AS AN ORDER) DISCONTINUE RENEW AS ORDERED RENEW PER THERAPIST’S MODIFICATIONS MODIFY THERAPY TO:______________________________________________ PHYSICIAN’S SIGNATURE/DATE:______________________________________ RESPIRATORY CARE DEPT. FUNCTION TECH. __________________________ A. CLEANING __________________________ B. REASSEMBLY __________________________ C. TEST RUN __________________________ D. COMMENTS: ___________ DATE: RT300-K 2” X 3” 300 PER ROLL PRICE GROUP 3 RT330-K 4” X 3” 300 PER ROLL PRICE GROUP 5 __/__/__ RESPIRATORY UPDATE PATIENT:________________________________________________RM#___________ RESP. STATUS: 1. Vent. Dependent (Refer to Flow Sheet Parameters) ____________________________________________________________________________________________ 2. Aerosol X hrs. H.M.E.X. Hrs. FiO2 % ____________________________________________________________________________________________ THERAPY: 1. H.H.N. 2. I.S. 3. M.D.I. 4. I.P.P.B. ____________________________________________________________________________________________ VITALS: 1. B.P.M. 2. Pulse 3. B/P ____________________________________________________________________________________________ AUSCULTATION: 1. Wheeze 2. Rales 3. Rhonchi 4. Clear ____________________________________________________________________________________________ ____________________________________________________________________________________________ COUGH: 1. YES 2. NO 3. Prod. 4. Non-Prod. SPUTUM: 1. Mucoid 2. Mucopurulent 3. Purulent ____________________________________________________________________________________________ 4. Cruantum 5. Rusty 6. Other ____________________________________________________________________________________________ PATIENT RESPONSE: 1. Stable 2. Improving ____________________________________________________________________________________________ 3. Declining 4. Resp. Distress ____________________________________________________________________________________________ TRACH CARE: 1. Dressings Changed Out X ____________________________________________________________________________________________ 2. Trach Replaced Y N / / ____________________________________________________________________________________________ 3. Condition: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ABG/OX: PH__________PCO2 ____________PAO2 ___________SAO ____________ 2 13400-14 4” X 3” 300 PER ROLL PRICE GROUP 5 REV 1/07 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 ________ ________ ________ PHYSICAL THERAPY LABELS Date Time Prob.# PARTICIPATION LEVEL: ACTIVE MODERATE MINIMAL NONE _________________________________________________________________________________________________________________________________________________________________ PARTICIPATION QUALITY: APPROPRIATE ATTENTIVE SHARING SUPPORTIVE INTRUSIVE MONOP0LIZING RESISTANT DROWSY OTHER:_________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________ AFFECT: APPROPRIATE EXCITED ANXIOUS DEPRESSED LABILE ANGRY FLAT _________________________________________________________________________________________________________________________________________________________________ COGNITIVE: APPROPRIATE ORIENTED CONFUSED ALERT DELUSIONAL HALLUCINATING _________________________________________________________________________________________________________________________________________________________________ INSIGHT/ENGAGEMENT IN THERAPY: NONE MINIMAL ALLIANCE FORMING _________________________________________________________________________________________________________________________________________________________________ MODES OF INTERVENTION: CLARIFICATION EXPLORATION LIMIT-SETTING ORIENTATION REALITY-TESTING CONFRONTATION ROLE-PLAY PLAY THERAPY SUPPORT EDUCATION PROBLEM-SOLVING SOCIALIZATION REMINISCENCE ACTIVITY MOVEMENT OTHER:___________________________________________________ _________________________________________________________________________________________________________________________________________________________________ TYPE OF THERAPY/TOPIC____________________________________________________________________________________________________________________________________________ SUMMARY OF PROGRESS/PROBLEMS ADDRESSED:_______________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________ GROUP THERAPY PROGRESS NOTES__________________________________________________________________________ Signature 13300-83 2.5" X 7" 250 PER ROLL PRICE GROUP 3 Daily Progress Documentation Physical Therapy Bed Mobility 1. Rolling Circle issues & document this notification in the Medical Record. Rehabilitation Screening x7114 No referral needed Physical Therapy 1. Recent falls, loss of balance, weakness, dizziness, syncope 2. Use of furniture/walls for balance 3. Unable get in/out of a chair bed 4. Numbness/tingling in feet Occupational Therapy 1. Help with dressing, bathing, personal hygiene, toilet 2. Help with meal preparation 3. Numbness, tingling or loss of hand strength Speech Therapy 1. Difficulty swallowing, cough/choking after drinking 2. Difficulty w/slurred speech, hearing, expressing self, understanding Brochure given 13300-121 2" x 3" 300 PER ROLL PRICE GROUP 3 Function R L Ambulation: Function 13. Level surface: 2. Supine to sit: 14. Turns: 3. Sit to supine 15. Distance Transfers: 16. Assistive device: 4. 17. Weight bearing Total Hip Precautions 5. Sit to stand: 6. Bed to chair: 1/3 7. Bed to chair: 2/3 3/3 TKR exercise protocol 8. Other TKR exercise protocol Balance: Static THER exercise 9. Sitting: CPM 10. Standing Home Program Balance: Dynamic Pt/Family Education 11. Sitting 12. Standing Follows verbal / tactile cueing: consistently Demonstrates safety awareness: good 15270-55 4" x 3" 300 PER ROLL PRICE GROUP 5 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 inconsistently fair poor PHYSICAL THERAPY LABELS PAIN MANAGEMENT N/A Goal: Post intervention pain rating is < pre-intervention pain rating PAIN SCALE PAIN INTESITY LEGEND 10 9 8 7 6 5 4 3 2 1 0 TRIAGE A POINT TRIAGE B C RN Initials _______ D E TIME F G H I TIME _____ A _____ B _____ C _____ D _____ F _____ G _____ H _____ I _____ _________ _________ 13300-117 4" x 4" 250 PER ROLL PRICE GROUP 5 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 RADIOLOGY LABELS PORTABLE EXAMINATION ERECT PA _____ SEMI ERECT AP OR HOURS SUPINE X-TABLE _____ ____ MAS KVP Tachnologist________________________________________________ XX291-K 1" X 3" 300 PER ROLL PRICE GROUP 2 FI102 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 RIGHT FI101 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 NM051-K 1" X 3" 300 PER ROLL PRICE GROUP 2 ERECT RECUMBENT L E F T XX144-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 ______________________________ SEMI - ERECT PA AP _____________________________________________________________________ LXB-81 7/8" X 3" 500 PER ROLL PRICE GROUP 4 SSR-1 1/2" X 1.5" 1000 PER ROLL PRICE GROUP 2 RIGHT PORTABLE ERECT SEMI-ERECT SUPINE PA AP ____ DIST. ______KV ____MAS OR RECOVERY ER DATE _____________TIME _______________ XX145-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 WET READING LEFT PORTABLE TECHNIQUE HT116-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 R I G H T LEFT NUCLEAR MEDICINE COMPLETED DATE ____________TIME ______________________ DISTANCE STAT SSR-2 1/2" X 1.5" 1000 PER ROLL PRICE GROUP 2 UPRIGHT XX120-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 WITHOUT CONTRAST FI140-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 WITH CONTRAST NM134-K 3/8" X 1.25" 500 PER ROLL PRICE GROUP 1 MRI FILM#______OF_____ XX564-K 7/8" X 3" 500 PER ROLL PRICE GROUP 4 XX518-K 1/2" X 1.5" 1000 PER ROLL PRICE GROUP 2 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 SSR-485A 1/2" X 1.5" 1000 PER ROLL PRICE GROUP 2 PORTABLE RADIOLOGY LABELS POSITION_______________________ TIME___________________________ ATTENTION!!! DATE___________________________ Due to table weight limits and for your TECHNIQUE___________DIST______ SAFETY-PLEASE DO NOT TAKE THIS PREP KIT, if your weight exceeds 300 lbs. Please call San Antonio Radiology Dept. (909)920-4710 for assistance 9100-47 1.5" X 3" 300 PER ROLL PRICE GROUP 3 PORTABLE- Position_____________________ DATE__________________TIME____________ TECHNIQUE______________________BY____ XX115-K 1" X 3" 300 PER ROLL PRICE GROUP 3 3D 12000-109 4" x 3" 300 PER ROLL PRICE GROUP 4 THIS IS A TEMPORARY LOAN JACKET THESE X-RAYS ARE PART OF THE PATIENT'S PERMANENT RECORD. PLEASE RETURN TO: HEMET VALLEY MEDICAL CENTER 14900-131 1/2" X 1.5" 500 PER ROLL PRICE GROUP 2 X-RAY COPIES DO NOT RETURN DEPARTMENT OF RADIOLOGY 1117 EAST DEVONSHIRE AVENUE HEMET, CALIFORNIA 92543 (909) 652-2811 EXT 5008 NAME:_______________________ M/R#:________________________ XX207-K 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 15270-27 4" X 3" 300 PER ROLL PRICE GROUP 4 Revised: 4/04 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 RADIOLOGY LABELS REACTION FROM X-RAY CONTRAST ENT CLINIC- OUTSIDE FILMS PATIENT NAME:____________________ MEDICAL RECORD#:________________ ENT PHYSICIAN:___________________ DATE RECEIVED:___________________ DATE TO RETURN:__________________ Patient________________________ Exam_________________________ Type of Reaction________________ Allergic To_____________________ RETURN FACILITY: Medication Given_______________ NAME:____________________________ PHONE:___________________________ Time_________________________ By Whom______________________ X-RAY COPIES-DO NOT RETURN XX401-K 2.5" X 2.5" 200 PER ROLL PRICE GROUP 3 50000-10 3" X 4" 300 PER ROLL PRICE GROUP 4 PORTABLE (OR) DATE___________TIME________BY_____________ ERECT SEMI-ERECT SUPINE AP TECHNIQUE_______________DISTANCE_________ MAS__________KVP____________BY____________ CHEMOTHERAPY XX705-K 1" X 3" 300 PER ROLL PRICE GROUP 3 DISPOSE OF PROPERLY BE285-K 1” X 3” 300 PER ROLL PRICE GROUP 3 X-RAY EXAMINATION COMPLETED ON ____________ GB BE UGI IVP SM. BOWEL OTHER:_________ 15270-107 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 Revised: 9/06 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 RADIOLOGY LABELS NUCLEAR MEDICINE MEDICAL HISTORY: ____________________________________________________________________ COMPLAINT: ____________________________________________________________________ PREVIOUS STUDIES: ____________________________________ YEAR __________________________ OUTSIDE STUDIES: YES/NO_____________________________________________________________ DOSAGE:________________TECH:__________________________________EXT:____________________ COMMENTS:____________________________________________________________________________ 9100-141 3” X 5” WHITE W/ BLK PRINT PRICE GROUP 5 C.T. SCAN COMPLETED XRAY COMPLETED Study_________________________________ EXAM_________________________________ Date__________________________________ CONTRAST____________________________ Technologist___________________________ DATE_________TIME___________BY_______ XX219-K 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 CT Contrast Agent (Administer per Instructions) (Not for IV use) 3500-68 1” x 2.5” 300 PER ROLL PRICE GROUP 2 Revised: 1/07 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 15270-108 7/8” X 2.25” 420 PER ROLL PRICE GROUP 2 RADIOLOGY LABELS CONTRAST Type__________Strength_________ Date______Time_________Intls_____ 7/8” x 2.25” 420 per roll CONTRAST Type__________Strength_________ Date______Time_________Intls_____ 1” x 3” 300 per roll Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 DATE-ITS 2007 RED WITH YELLOW PRINT 1 JAN. 2007 1 JAN. 2007 1 JAN. 2007 STOCK # 2007-50 SET OF 50 PER DAY STOCK # 2007-100 SET OF 100 PER DAY STOCK # 2007-200 SET OF 200 PER DAY STOCK # 2007-300 SET OF 300 PER DAY STOCK # 2007-400 SET OF 400 PER DAY STOCK # 2007-500 SET OF 500 PER DAY 1 JAN. 2007 1 JAN. 2007 YELLOW WITH BLACK INK STOCK# 2007-20 SET OF 20 ON A PAGE Yellow Date Labels Available From Laguna Coast Associates 22 OCT 2007 HR. MIN. AM 22 OCT 2007 HR. PM CM CM MIN. AM PM 22 OCT 2007 HR. MIN. AM 22 OCT 2007 HR. PM CM MIN. AM PM CM Date Labels with Ruler TYPE 100 / day 200 / day 300 / day 400 / day 500 / day 1000 / day Quantity per Roll 100 labels per roll 200 labels per roll 300 labels per roll 400 labels per roll 500 labels per roll 1000 labels per roll Stock # YDR-100 YDR-200 YDR-300 YDR-400 YDR-500 YDR-1000 Let Laguna Coast Be Your One Stop For All Your Radiology Label Needs. Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest CA 92630 Order Desk (949) 455-2500 FAX (949) 455-1133 FORM#YDL01 CUSTOM LABELS Westcliff Medical Laboratory PRE-OP/SURGERY LAB TESTING DATE OF SURGERY:_________TIME:_________ LOCATION OF SURGERY:__________________ CHECK ONE FAX TO LA VETA SURGICAL CENTER (714)744-0283 ST. JOSEPH'S IN-PATIENT (714)744-8562 PAVILION SURGERY CENTER (714)744-8682 OTHER FAX# IMC (949)753-2059 IV LABEL PT. Name:__________________________ Room No.:__________________________ Bottle No.:__________________________ Solution:___________________________ Medication & Amount Added:__________ ___________________________________ ___________________________________ Prep. Date & Time____________________ Prep. By:___________________________ Start Date & Time____________________ Rate:______________________________ Comments:_________________________ Expires after 24 hours from time mixed Beverly Hospital, 309 W. Beverly Blvd. Montebello, CA 90640 (213)726-1122 15660-21 3" X 4" 300 PER ROLL PRICE GROUP 4 INTRAVENOUS SOLUTION BOTTLE # Rm. # RN. ____________________ NAME ID# UNIT DUE R E F R I G E R A T E 2000-58 4" x 3" 300 PER ROLL PRICE GROUP 4 PLEASE RETURN! THIS FILM IS PART OF THE PERMANENT RECORD DEPARTMENT OF RADIOLOGY ST. JOSEPH HOSPITAL Children's Hosp. of Orange Co. DO NOT INFUSE AFTER ST. JOSEPH HOSPITAL-CHILDRENS HOSPITAL OF ORANGE DEPARTMENT OF PHARMACY 1100 WEST STEWART DR. PO BOX 5600 ORANGE,CA PHONE (714)771-8148 13800-41 2" X 3" 300 PER ROLL PRICE GROUP 3 IV602-K 3" X 4" 300 PER ROLL PRICE GROUP4 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 CUSTOM LABELS HEPARIN INFUSION CONVERSION CHART CARDIOLOGY SAN ANTONIO COMMUNITY HOSPITAL 999 San Bernardino Road Upland, California 91786 (909) 920-4705 Heparin 25,000 Units/250 ml Standard Concentration: 100 units/ml DOSAGE (Units/Hour) INFUSION RATE (ml/Hour) 500 - - - - - - - - - - - - - - - 600 - - - - - - - - - - - - - - - 700 - - - - - - - - - - - - - - - 800 - - - - - - - - - - - - - - - 900 - - - - - - - - - - - - - - - 1,000 - - - - - - - - - - - - - - - 1,100 - - - - - - - - - - - - - - - 1,200 - - - - - - - - - - - - - - - 1,300 - - - - - - - - - - - - - - - 1,400 - - - - - - - - - - - - - - - 1,500 - - - - - - - - - - - - - - - 1,600 - - - - - - - - - - - - - - - 1,700 - - - - - - - - - - - - - - - 1,800 - - - - - - - - - - - - - - - 1,900 - - - - - - - - - - - - - - - 2,000 - - - - - - - - - - - - - - - - 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Dosage increase of 100 units/hour may be obtained by increasing infusion rate by 1ml/hour. PHARMACY/IV THERAPY MAYO CLINIC HOSPITAL 12000-111 1.5" X 3" 300 PER ROLL PRICE GROUP 3 AM DATE____/____/___TIME______ PM AM DATE____/____/___TIME______ PM AM DATE____/____/___TIME______ PM AM DATE____/____/___TIME______ PM AM DATE____/____/___TIME______ PM AM DATE____/____/___TIME______ PM AM DATE____/____/___TIME______ PM AM DATE____/____/___TIME______ PM AM DATE____/____/___TIME______ PM AM DATE____/____/___TIME______ PM AM DATE____/____/___TIME______ PM AM DATE____/____/___TIME______ PM WESTCLIFF MEDCIAL LAB 8975-06 3.5" X 5" 200 PER ROLL PRICE GROUP 4 15660-79 2.75" X 2.75" 200 PER ROLL PRICE GROUP 3 * ALL LABELS CAN BE CUSTOMIZED PER FACILITY Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 CUSTOM LABELS Manufacturer#________________________ Oral Contrast 5cc Expires______________________________ Foothill Presbyterian Hospital Radiology For Outpatients Use Only COTTAGE HOSPITAL EYE CENTER P.O. BOX 689 SANTA BARBARA, CA. 93102 4325-08 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 5200-09 1" x 3" 300 PER ROLL PRICE GROUP 3 ABO Group and Rh (if Negative) Confirmed By: Glendale Memorial Hospital & Health Center POST-OP Pain Management/Epidurals Dr. E. CARREGAL (626)818-5177 (323)254-4598 5720-21 7/8" x 1 5/8" 500 PER ROLL PRICE GROUP 2 6700-98 1" X 3" 300 PER ROLL PRICE GROUP 3 PROPERTY OF Verdugo Hills Hospital Pharmacy 1812 Verdugo Blvd. Glendale, Calif. 91208 (818)952-2224 No. CRITICAL CARE SYSTEMS IF FOUND CALL TOLL FREE 866-508-2990 Dr. 50007-01 7/8" X 2.25" 420 PER ROLL PRICE GROUP 2 Discard After: ___________________________________________________________ CAUTION: FEDERAL LAW PROHIBITS THE TRANSFER OF THIS DRUG TO ANY PERSON OTHER THAN THE PATIENT FOR WHOM IT WAS PRESCRIBED. Focus Medical Mfg. LLC .. 1016 N. Johnson Bay City, MI 48708 1 800 729-0032 15300-04 2" X 3" 300 PER ROLL PRICE GROUP 3 6000-20 1" x 3" 300 PER ROLL PRICE GROUP 3 Revised: 4/04 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 CUSTOM LABELS CAST COAT is a product of Focus Medical Mfg. LLC Bay City, Michigan 48708 USA For More Information Call 1 800 729-0032 . . BIOMED (ANYTIME) 816-1071 14295-10 1” X 3” 300 PER ROLL PRICE GROUP 3 6000-21 1.5" x 3" 300 PER ROLL PRICE GROUP 3 Website: www.castcoat.net 5150 Further Processed by SM-UCLA MEDICAL CENTER BLOOD BANK Santa Monica, CA 90404 DATE______________BEGINS____________ 6000-22 3/8" x 1.25" 500 PER ROLL PRICE GROUP 1 14900-132 1/2" x 1 1/2" 500 PER ROLL PRICE GROUP 2 DATE______________ENDS______________ 13800-169 1” X 2.5” FL GREEN 300 PER ROLL PRICE GROUP 2 NAME______________________AGE__________ EXAM NO._______________DATE_____________ Center For Breast Care 11190 WARNER AVE, SUITE 214 FOUNTAIN VALLEY, CA 92708 5215-14 1" X 3" 300 PER ROLL PRICE GROUP 3 Website: FREE HIPAA FOLDER PRINTING WITH ORDERS OF 500 FOLDERS OR MORE www.focusmedicalmfg.com 6000-25 3/8" x 1.25" 500 PER ROLL PRICE GROUP 1 7025-36 1.5” X 3” FL ORANGE 300 PER ROLL PRICE GROUP 3 Revised: 9/06 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 CUSTOM LABELS HIGH FALL RISK ATTENTION HiLo Evac ETT. Connection of white port to suction source required 6700-138 1” x 3” FL RED 300 PER ROLL PRICE GROUP 2 Pt. Rm. No. _________________________________________________ YES NO Any YES indicates HIGH RISK _________________________________________________ Previous Fall _________________________________________________ Mobility Problem _________________________________________________ Confusion or Intermittent Confusion _________________________________________________ Incontinent _________________________________________________ Hearing or Visual Impairment _________________________________________________ Receiving Hypnotics, Laxatives or Diuretics _________________________________________________ Pt. Is 70+ _________________________________________________ Post Operative Pt. _________________________________________________ Child is 3 yrs. and under _________________________________________________ DILATION FOR ADULTS 6000-26 2.5” x 2.5” FL PINK 250 PER ROLL PRICE GROUP 3 Proparacaine HCI 0.5% Tropicamide 1% Phenylephrine HCI 2.5% SIGN________________________ CHN_________________________ 50000-29 2” X 3” WHITE W/ BLK PRINT PRICE GROUP 3 DONOR CHOC CORD BLOOD BANK Please call CBB staff at: 63-4060 or page: 9-275-1208 9-275-1403 4 x 3 Fl Green $22.50/Roll/300 ea Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 PPD: 0.1ml PPD ---- ---- CLINIC VACCINE LABELS HIB: 0.5ml HI PPD-TAN ---- HI- PINK ---- FLU: F IPV: 0.5ml IP F- RED ---- IP- AQUA ---- VZV: 0.5ml V MMR: 0.5ml M V- ROSE PX P- ORANGE ---- PX- LAVENDER DTaP: 0.5ml DTaP PDRX: 0.5ml TD ---- P ---- ---- M-GRAY PCV7: 0.5ml TD: 0.5ml DTaP- YELLOW ---- TD- COPPER HEPA: 0.5ml ---- HA HB HA- LIME HB- BLUE ---- PCV23 ---- PCV MEN PCV- SALMON MENingococcal MEM- WHITE SPECIAL TABS FOR PRE-LABELING VACCINES FOR IMMUNIZATIONS ---- CHH HEPB: 0.5ml COMVAX: 0.5ml CHH- WHITE CAN PRINT CUSTOM TEXT! CAN USE IN CHARTS TO RECORD HISTORY. ROOM TO RECORD LOT NUMBERS USED AND MANUFACTURE. Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 * PARKING * * VIOLATION * * * PARKING VIOLATION 9000-39 2.5” X 2.5” FL GREEN W/ BLACK PRINT $28.50 PER ROLL 250 LABELS PER ROLL REMOVEABLE ADHESIVE 9000-39 1.5” X 3” FL RED W/ BLACK PRINT $15.25 PER ROLL 300 LABELS PER ROLL REMOVEABLE ADHESIVE PARKING VIOLATION 9000-39 7/8” X 2.25” YELLOW W/ BLACK PRINT $21.50 PER ROLL 420 LABELS PER ROLL REMOVEABLE ADHESIVE Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 VISITOR PASSES VISITORS PASS Name______________________________ Date______________Room No._________ THANKS FOR NOT SMOKING GENERIC VISITOR PASS BR201 BR202 BR203 BR204 BR205 BR206 BR207 BLUE ORANGE GREEN BROWN RED BLACK PURPLE BR205 2" X 3" 500 PER ROLL PRICE GROUP 3 COASTAL COMMUNITIES HOSPITAL VISITORS PASS SATURDAY Name:__________________________ Location:_____________Date:_______ CONTRACTOR PASS _________________ NAME: _________________ DATE: AUTHORIZATION: _________________ St. Mary Medical Center 14295-09 2" x 3" 500 PER ROLL PRICE GROUP 3 3840-20 2" x 3" 500 PER ROLL PRICE GROUP 3 *ALL VISITOR PASSES CAN BE CUSTOMIZED PER FACILITY Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 VISITOR PASSES KINDRED ARROWHEAD REGIONAL MEDICAL CENTER NAME:_______________________ CO. NAME:___________________ DATE:_______________________ AREA VISITED:________________ Name___________________________________ VISITOR / VENDOR VISITORS PASS _______________ Date_________________Room No.__________ THANKS FOR NOT SMOKING 10850-32 2" X 3" 500 PER ROLL PRICE GROUP 3 15275-08 2" X 3" 500 PER ROLL PRICE GROUP 3 Glendale Memorial Hospital and Health Center CHW BUSINESS REPRESENTATIVE Visitor Pass Room:_______Date:______ Please wear this pass at all times. Visiting hours are 11am to 8pm. Please, only 2 visitors per patient. Check with the nurse for visitors under 14. Date_________________________________ Destination___________________________ _____________________________________________________________ THANKS FOR NOT SMOKING 5720-15 2" x 3" 500 PER ROLL PRICE GROUP 3 Revised: 4/04 BR101-K 2" x 3" 500 PER ROLL PRICE GROUP 3 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133 VISITOR PASSES VISITOR PASS DESTINATION________________________ NAME OF VISITOR____________________________ DATE______________________________ 3840-26 3” X 2” 300 PER ROLL PRICE GROUP 3 KINDRED EMPLOYEE NAME:________________ DEPT:_________________ DATE:_________________ 3840-26 3” X 2” 300 PER ROLL PRICE GROUP 3 Revised: 8/04 Laguna Coast Associates, Inc. 26774 Vista Terrace Lake Forest, California 92630 Ph 949-455-2500 Fax 949-455-1133
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