ALL ORDERS MUST BE WRITTEN WITH A BALL POINT PEN AND INCLUDE DATE, TIME, AND PHYSICIAN’S SIGNATURE.

PHYSICIAN’S ORDER DATE TIME INTRAVENOUS FLUID and MEDICATION

(EXCLUDING IV Fluids and MEDICATIONS) ORDERS
ICU Admission Orders—Page 1 of 5 ALLERGY:
DATE: _________________ TIME: _______________

IVF and MEDICATION ORDERS ONLY

Admitting MD: ____________________________
IV Fluids
Diagnosis:_________________________________ □ 1000 mL 0.9% sodium chloride IV to run at _____
mL/hr x _____ liters.
__________________________________________
□ 1000 mL: 5%dextrose IV to run at ____mL/hr x
__________________________________________ __________ liters.
Comorbidities/History □ Add □ 20 mEq □ 40 meq Potassium chloride to
□ CAD □ PVD □ COPD □ Smoker each liter of IV fluid.

IVF and MEDICATION ORDERS ONLY

□ CA □ CVA □ Trauma □ HTN
□ CHF □ DM □ Sepsis □ CRF □ Other IV fluids; ___________________________
□ ESRD □ Hemodialysis
□ Trauma _______________ Anticoagulation
□ Cardiomyopathy □ Immunosuppressed □ Enoxaparin (Lovenox) - See attached order form.
□ Poor Nutrition □ Other: ___________________________________
□ Acute Coronary Syndrome
________________________________________
□ Other: ___________________________________
Activities
DVT Prophylaxis
IVF and MEDICATION ORDERS ONLY

□ Bed rest
□ Tedhose/Pneumatic Stockings
□ Other ___________________________________
□ Sequential Compression Device
□ Heparin – See attached order form.
Diet: _____________________________________
□ Enoxaparin (Lovenox) - See attached order form.
Consults:
□ Cardiology/ Dr. ___________________________ □ Other: ___________________________________
□ Renal/ Dr. _______________________________ _________________________________________
□ Pulmonary/ Dr. ___________________________
Stress Ulcer/GI Bleed Prophylaxis
IVF and MEDICATION ORDERS ONLY

□GI/Dr. ___________________________________
□ Zantac 50 mg IV q 8 hours.
□ GU/ Dr. _________________________________ □ Pantoprazole (Protonix) 40 mg IV q 24 hours.
□ Neurologist/ Dr. ___________________________ □ Sulcralfate (Carafate) 1 gram via NG/OG Tube
□ Nuerosurgeon/ Dr. _________________________ every 6 hours.
□ Psychiatry/Dr. ____________________________ □ Other: ___________________________________
□ ID/Dr. ___________________________________
__________________________________________
□ Surgical/ Dr. ______________________________
__________________________________________
for □ Central Line □ Other: _________________

Continued on next page >>>>>> Continued on next page >>>>>>

 Summary/Blanket orders are unacceptable.

PATIENT ID LABEL
DO NOT USE:
 Medication orders must be complete. U MS MD initials:
 PRN medication orders must include an indication. IU MSO4
 Write legibly. Q.D. MgSO4
 Rewrite orders upon transfer and/or post-operatively. Q.O.D. Trailing zero
 Date, time, and sign verbal & telephone orders within 48 hours. Lack of leading zero

Physician’s Order Form (Page 1 of 5)

ICU Admission Order Set
GMHA #049063 Stock # 99049063
APPROVED DATE: Medicine Dept. 10/2010, MEC 07/2011, HIMC 03/2012
 ALL ORDERS MUST BE WRITTEN WITH A BALL POINT PEN AND INCLUDE DATE, TIME, AND PHYSICIAN’S SIGNATURE.
PHYSICIAN’S ORDER DATE TIME INTRAVENOUS FLUID and MEDICATION
(EXCLUDING IV Fluids and MEDICATIONS) ORDERS
ICU Admission Order Set – Page 2 of 5 ALLERGY:
□ Dietary

IVF and MEDICATION ORDERS ONLY

□ PT/OT
□ Social Service: ____________________________ Pain
□ Other: ___________________________________ □ Morphine Sulfate 1 – 4 mg IV every 1 hour PRN
for mild pain.
Code Status:
□ Morphine Sulfate 5 – 8 mg IV every 1 hour PRN
□ Full ACLS
for moderate pain.
□ No Defibrillation
□ Morphine Sulfate 9 – 12 mg IV every 1 hour PRN
□ No Intubation
for severe pain.
□ No Chest Compressions

IVF and MEDICATION ORDERS ONLY

□ Morphine Sulfate _____ mg IV every _____ hour
□ No ACLS Interventions (Do Not Resuscitate):
PRN for _________________________________
continue care as ordered.
□ Other: ___________________________________
□ Other ___________________________________
_________________________________________
_________________________________________
Nausea
Treatments:
□ Ondansetron (Zofran) 4 mg IV every 8 hours PRN
□ Vital Signs Routine per ICU/CCU Protocol
for nausea.
IVF and MEDICATION ORDERS ONLY

□ Pulse Oximetry
□ Promethazine (Phenergan) 25 – 50 mg IV every 4
□ Nasal Canula 2 – 6 liters/hr as needed to
hours PRN for nausea.
maintain oxygen saturation > 90%.
□ Properidol (Inapsine) 0.625 mg IV every 4 hours
□ Foley Catheter to drainage bag.
PRN for nausea.
 Weights □ Every other day □ Daily □ Other: __________________________________
 OG Tube □ Intermittent Suction □ Gravity ________________________________________
□ Clamp
□ Venous Thromboembolism Prophylaxis Other Medications
IVF and MEDICATION ORDERS ONLY

□ Other: ___________________________________ ( ) _______________________________________

_________________________________________
_______________________________________
□ BiPap Settings: __________________________ ( ) _______________________________________
__________________________________________ _______________________________________

Continued on next page >>>>>> ( ) _______________________________________

_______________________________________
Continued on next page >>>>>>

 Summary/Blanket orders are unacceptable.

PATIENT ID LABEL
DO NOT USE:
 Medication orders must be complete. U MS MD initials:
 PRN medication orders must include an indication. IU MSO4
 Write legibly. Q.D. MgSO4
 Rewrite orders upon transfer and/or post-operatively. Q.O.D. Trailing zero
 Date, time, and sign verbal & telephone orders within 48 hours. Lack of leading zero

Physician’s Order Form (Page 2 of 5)

ICU Admission Order Set
GMHA #049063 Stock # 99049063
APPROVED DATE: Medicine Dept. 10/2010, MEC 07/2011, HIMC 03/2012
 ALL ORDERS MUST BE WRITTEN WITH A BALL POINT PEN AND INCLUDE DATE, TIME, AND PHYSICIAN’S SIGNATURE.
PHYSICIAN’S ORDER DATE TIME INTRAVENOUS FLUID and MEDICATION
(EXCLUDING IV Fluids and MEDICATIONS) ORDERS
ICU Admission Order Set – Page 3 of 5 ALLERGY:

□ Ventilator Settings:

IVF and MEDICATION ORDERS ONLY

FiO2 _______________ TV _______________ □ POTASSIUM REPLACEMENT PROTOCOL
PEEP _____________ AC _______________ (NOT for use with Renal Patients)
PS _____________ Rate _______________
 Check potassium level.
 Discontinue potassium protocol if serum
□Ventilator Bundle (for all ventilator patients): creatinine is greater than 3 mg/dL and call
 HOB 30 degrees. physician for orders.
 Daily “sedation wakeup”.  Once potassium is WNL, ask physician for oral

IVF and MEDICATION ORDERS ONLY

 Daily assessment for weaning from ventilator. potassium order.
 Oral Care every 2 hours (with antiseptic
solution). □ If potassium level LESS THAN 3.5 mg/dL:
 ABG every morning  Central Line: Infuse Potassium Chloride 40
mEq IV in 100 mL NSS over 2 hours.
Additional Pulmonary Orders:  Peripheral Line: Infuse Potassium Chloride 20
( ) _______________________________________ mEq IV in 100 mL NSS x 2 doses over 4 hours
of total dose of 40 mEq. Infuse at 50 mL/hr.
IVF and MEDICATION ORDERS ONLY

_______________________________________
 Repeat Potassium Level 3 hours after infusion
( ) _______________________________________ complete.
_______________________________________
( ) _______________________________________ □ If potassium level 3.5 mg/dL – 3.9 mEq/L:
 Central Line: Infuse Potassium Chloride 20
_______________________________________
mEq in 100 mL NSS over 1 hour.
 Peripheral Line: Infuse Potassium Chloride 20
STAT Labs and Diagnostics:
IVF and MEDICATION ORDERS ONLY

mEq in 100 mL NSS over 2 hours. Repeat

□ CBC (auto diff) □ Liver Panel
Potassium Level 3 hours after infusion complete.
□ CBC (manual diff) □ UA
□ PT/PTT □ D-Dimer
□ If potassium level GREATER THAN 5.5
□ Finger Stick for BS □ Lactate
mEq/L:
□ ABG □ BNP
 STOP ALL ORAL AND IV POTASSIUM AND
□ CHEM 7 □ Magnesium
NOTIFY PHYSICIAN.
□ Phosphorus □ Amonia
□ Calcium □ LDH
Continued on next page >>>>>>
Continued on next page >>>>>>
 Summary/Blanket orders are unacceptable.
PATIENT ID LABEL
DO NOT USE:
MD initials:
 Medication orders must be complete. U MS
 PRN medication orders must include an indication. IU MSO4
 Write legibly. Q.D. MgSO4
 Rewrite orders upon transfer and/or post-operatively. Q.O.D. Trailing zero
 Date, time, and sign verbal & telephone orders within 48 hours. Lack of leading zero

Physician’s Order Form (Page 3 of 5)

ICU Admission Order Set
GMHA #049063 Stock # 99049063
APPROVED DATE: Medicine Dept. 10/2010, MEC 07/2011, HIMC 03/2012
 ALL ORDERS MUST BE WRITTEN WITH A BALL POINT PEN AND INCLUDE DATE, TIME, AND PHYSICIAN’S SIGNATURE.
PHYSICIAN’S ORDER DATE TIME INTRAVENOUS FLUID and MEDICATION
(EXCLUDING IV Fluids and MEDICATIONS) ORDERS
ICU Admission Order Set – Page 4 of 5 ALLERGY:

STAT Labs and Diagnostics continued:

IVF and MEDICATION ORDERS ONLY

□ CPK, MB, Troponin □ Chem 20
□ MAGNESIUM REPLACEMENT PROTOCOL
□ Culture □ Urine
(NOT for use with Renal Patients)
□ Sputum □ Stool
 Check Magnesium Level.
□ Blood x ____
□ Other: ___________________________________ □ If magnesium level 1.6 – 1.7 mg/dL:
 Infuse 2 gram Magnesium Sulfate in 250 mL
□ CT Scan of: ______________________________ NSS IV over 8 hours.
□ With Contrast: □ IV □ Oral □ NGT  Repeat serum Magnesium Level 8 hours after

IVF and MEDICATION ORDERS ONLY

□ OGT □ PEG □ Rectal completion of infusion.
□ WithOUT Contrast
□ Portable CXR □ If magnesium level 1.4 – 1.5 mg/dL:
□ Ultrasound of _____________________________  Infuse 4 grams Magnesium Sulfate in 250 mL
________________________________________ NSS IV over 8 hours.
□ Echocardiogram ___________________________  Repeat serum Magnesium Level 8 hours after
to interpret study. completion of infusion.
□ EKG
IVF and MEDICATION ORDERS ONLY

□ If magnesium level 1.2 – 1.3 mg/dL:

AM Labs and Diagnostics:  Infuse 6 grams Magnesium Sulfate in 250 mL
□ CBC (auto diff) □ Liver Panel NSS IV over 8 hours.
□ CBC (manual diff) □ UA  Repeat serum Magnesium Level 8 hours after
□ PT/PTT □ D-Dimer completion.
□ Lactate □ ABG
□ If magnesium level LESS THAN 1.2 mg/dL
□ BNP □ CHEM 7
WITH Seizures:
□ Magnesium □ Phosphorus
IVF and MEDICATION ORDERS ONLY

 Infuse 4 grams Magnesium Sulfate in 250 mL

□ Ammonia □ Calcium
D5W at a maximum rate of 3 mL/min.
□ LDH □ CPK, MB, Troponin
□ Accucheck Every _____
□ Culture □ Urine □ Sputum □ Urine
Continued on next page >>>>>>
□ Stool □ Other: ________________
□ CT Scan of: ______________________________
□ With Contrast: □ IV □ Oral
□ WithOUT Contrast
Continued on next page >>>>>>

 Summary/Blanket orders are unacceptable.

PATIENT ID LABEL
DO NOT USE:
 Medication orders must be complete. U MS MD initials:
 PRN medication orders must include an indication. IU MSO4
 Write legibly. Q.D. MgSO4
 Rewrite orders upon transfer and/or post-operatively. Q.O.D. Trailing zero
 Date, time, and sign verbal & telephone orders within 48 hours. Lack of leading zero

Physician’s Order Form (Page 4 of 5)

ICU Admission Order Set
GMHA #049063 Stock # 99049063
APPROVED DATE: Medicine Dept. 10/2010, MEC 07/2011, HIMC 03/2012
 ALL ORDERS MUST BE WRITTEN WITH A BALL POINT PEN AND INCLUDE DATE, TIME, AND PHYSICIAN’S SIGNATURE.
DATE TIME PHYSICIAN’S ORDER DATE TIME INTRAVENOUS FLUID and MEDICATION
(EXCLUDING IV Fluids and MEDICATIONS) ORDERS
ICU Admission Order Set – Page 5 of 5 ALLERGY:

AM Labs and Diagnostics continued:

IVF and MEDICATION ORDERS ONLY

□ Portable CXR
□ For Torsades de Pointes:
□ Ultrasound of _____________________________
 Bolus 1 gram magnesium Sulfate in 50 mL D5W
________________________________________
over 5 to 60 minutes.
□ Echocardiogram ___________________________
 Follow with 0.5 mg to 1 gram per hour—titrated
to interpret study.
to control Torsades.
□ EKG
 Discontinue after level is normal.
TORB: ____________________________________  Repeat Serum Magnesium 8 hours after

IVF and MEDICATION ORDERS ONLY

completion of infusion.
MD Signature: ______________________________
□ Vaccine Order
□ Pneumonia Vaccine
□ Influenza Vaccine

□ Wound Care Bundle

IVF and MEDICATION ORDERS ONLY

MD Signature: ______________________________
IVF and MEDICATION ORDERS ONLY

 Summary/Blanket orders are unacceptable.

PATIENT ID LABEL
DO NOT USE:
 Medication orders must be complete. U MS
 PRN medication orders must include an indication. IU MSO4
 Write legibly. Q.D. MgSO4
 Rewrite orders upon transfer and/or post-operatively. Q.O.D. Trailing zero
 Date, time, and sign verbal & telephone orders within 48 hours. Lack of leading zero

Physician’s Order Form (Page 5 of 5)

ICU Admission Order Set
GMHA #049063 Stock # 99049063
APPROVED DATE: Medicine Dept. 10/2010, MEC 07/2011, HIMC 03/2012