Slchcpoe.org

OR – Pharmacy Orders
ALL ORDERS MUST HAVE DATE, TIME WRITTEN, WRITER'S AND TRANSCRIBER'S LEGIBLE SIGNATURE (FIRST INITIAL, LAST NAME, TITLE) AND TRANSCRIPTION TIME. DIAGNOSIS AND ALLERGIES TO BE INCLUDED IN ALL ADMIT ORDERS.
Attending:
Diagnosis:
Allergies: (List or note NKA)
Authorization is hereby given to dispense the generic or chemical equivalent unless otherwise indicated by the words “No Substitute.” Orders – Signatures – Transcription Times
Anesthesia – Continuous Infusions
(Note: Appropriate weight based standard concentration drips will be dispensed)
អ Alprostadil
Baclofen (Please order in the specified increments)អ Test Dose 50 mcg/ml 1 mlអ Concentration 500 mcg/ml Volume needed:__________ ml (20 ml increments)អ Concentration 2000 mcg/ml Volume needed:__________ ml (10 ml increments) Caffeine Citrate Dose (based on citrate)អ 20 - 40 mg/kg = _____________ mg IV x 1 (500 mg max dose as citrate)Cidofovir (in Normal Saline)Concentration: អ 5 mg/ml OR
អ 7.5 mg/ml OR អ 10 mg/ml
Cocaine Topical Solutionអ 4% topical solution 4 ml vialEye Meds (check meds needed): អ Fortified Tobramycin អ Fortified Vancomycin អ Subconjunctival Gentamicin 40 mg/ml x 1 ml Mitomycin
អ 0.3 mg/ml Volume Needed: ______________ ml
អ 0.4 mg/ml Volume Needed: ______________ ml
អ 1 mg/ml Volume Needed: ______________ ml
Pneumococcal Vaccine (must have consent)
អ Prevnar 0.5 ml IM x 1 (use for patients less than 2 years old)
អ Pneumovax 0.5 ml IM x 1 (use for patients 2 years old or greater)
Ampicillin/Sulbactam (Unasyn) (Standardized Dosing)
Vancomycin/Gentamicin for Shunt Procedures (Preservative Free)
អ Vancomycin 5 mg/ml in NS 2 ml
អ Gentamicin 2 mg/ml in NS 0.23 ml
Other Orders:
PLEASE SEND ALL MEDICATIONS TO OR ROOM # _____________
DO NOT WRITE IN BARCODE AREA
OR – Pharmacy Orders
ALL ORDERS MUST HAVE DATE, TIME WRITTEN, WRITER'S AND TRANSCRIBER'S LEGIBLE SIGNATURE (FIRST INITIAL, LAST NAME, TITLE) AND TRANSCRIPTION TIME. DIAGNOSIS AND ALLERGIES TO BE INCLUDED IN ALL ADMIT ORDERS.
Attending:
Diagnosis:
Allergies: (List or note NKA)
Authorization is hereby given to dispense the generic or chemical equivalent unless otherwise indicated by the words “No Substitute.” Orders – Signatures – Transcription Times
Anesthesia – Continuous Infusions
(Note: Appropriate weight based standard concentration drips will be dispensed)
អ Alprostadil
Baclofen (Please order in the specified increments)អ Test Dose 50 mcg/ml 1 mlអ Concentration 500 mcg/ml Volume needed:__________ ml (20 ml increments)អ Concentration 2000 mcg/ml Volume needed:__________ ml (10 ml increments) Caffeine Citrate Dose (based on citrate)អ 20 - 40 mg/kg = _____________ mg IV x 1 (500 mg max dose as citrate)Cidofovir (in Normal Saline)Concentration: អ 5 mg/ml OR
អ 7.5 mg/ml OR អ 10 mg/ml
Cocaine Topical Solutionអ 4% topical solution 4 ml vialEye Meds (check meds needed): អ Fortified Tobramycin អ Fortified Vancomycin អ Subconjunctival Gentamicin 40 mg/ml x 1 ml Mitomycin
អ 0.3 mg/ml Volume Needed: ______________ ml
អ 0.4 mg/ml Volume Needed: ______________ ml
អ 1 mg/ml Volume Needed: ______________ ml
Pneumococcal Vaccine (must have consent)
អ Prevnar 0.5 ml IM x 1 (use for patients less than 2 years old)
អ Pneumovax 0.5 ml IM x 1 (use for patients 2 years old or greater)
Ampicillin/Sulbactam (Unasyn) (Standardized Dosing)
Vancomycin/Gentamicin for Shunt Procedures (Preservative Free)
អ Vancomycin 5 mg/ml in NS 2 ml
អ Gentamicin 2 mg/ml in NS 0.23 ml
Other Orders:
PLEASE SEND ALL MEDICATIONS TO OR ROOM # _____________
DO NOT WRITE IN BARCODE AREA

Source: http://slchcpoe.org/SetsPDFs/OR-%20Pharmacy%20Orders.pdf