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Pre Order Form, Template

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					                                                             Saint Luke’s South
                                                         Overland Park, KS 66213

                                                               Physician Orders
                                                                                                     Write Down and Read Back for all Verbal Orders
   DATE       TIME               ANOTHER MEDICATION SIMILAR IN FORM AND ACTION MAY BE DISPENSED PER MEDICAL STAFF POLICY

                                                                   Routine Pre-Op Orders
                                                          Dr. Mirabile, Dr. McCullough, & Dr. Sorrells


                         Orders that are checked will be implemented. Additions, Deletions or Modifications (including strike through)
                         of orders must be individually initialed.


                         1.    CBC on all patients
                         2.    HCG (Qual) on all females aged 11 to 50 with results available prior to surgery. May defer if patient
                               has had a hysterectomy or is post-menopausal or has had a missed AB. (May substitute UCG
                               sensitivity 25mL/U/mL)
                         3.    All other labs per Anesthesia
                         4.    Type and screen for missed abortion if blood type is not available
                         5.    EKG and chest x-ray per anesthesia
                         6.    Instruct on incentive spirometry (Inpatients only)
                         7.    Thigh High SCD’s
                         8.    For patients with known Mitral Valve Prolapse, administer 80 mg Gentamycin IV and 2 gms Ampicillin
                               IV in holding area, if not allergic. Contact physician if patient has known allergy
                         9.    Antibiotic:
                               Cefotetan 2 grams IV within 30 minutes of first incision. Repeat dosing if procedure lasts longer than 6
                               hours. If allergic to Penicillin administer Clindamycin 600 mg IV and Gentamicin 1.5 mg/kg IV 30
                               minutes prior to first incision. Repeat dosing if procedure lasts longer than 6 hours
                         10. Consent:
                                  See Site Verification Orders




Physician Signature:___________________________________________ Date:__________________ Time:__________________
ALLERGIES / INTOLERANCES                                                         Affix Patient Label To ALL Pages
                                                            DANGEROUS ABBREVIATIONS
                                                                   – DO NOT USE!
Height ______                                               MS, MSO4, MgSO4, q.d. or QD,
                                                               q.o.d. or QOD, U or u, IU
Weight ______       kg        grams
Latex Allergy Yes        No
Page 1 of 1                                           Never use zero after decimal point (1.0 mg)
SLS-PACU-282 (Rev. 04/15/10)                         Always use zero before decimal point (0.5 mg)

				
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