Name: ___Juan Dela Cruz_________ Age: _55y.o_ Sex: _Male_ Hospital No.

: _10__
Ward / Room: _55_
DOCTOR’S ORDER/NURSE’S COMPLIANCE SHEET
(Authenticate All Orders)
Time Posted
Signature
C A R E D
Date, Time &
Notes ORDER
09/02/2021 Please admit to Surgery / 4:15pm/
4:00pm
Secure consent to care / 4:15pm/

NPO / 4:15pm/

NOT FOR
Start IVF of Plain NSS 1L at 20 drops/min / 4:15pm/

For Emergency Appendectomy under spinal / 4:15pm/

anesthesia 

Secure consent for the procedure / / 4:15pm/

For pre-op order

REPRODUCTIONCeftriaxone 1g IVTT ANST on call to OR

Ranitidine 50 mg IVTT on call to OR

Secure two units of Packed RBC, properly

screened, and cross matched standby for OR
/

/
/
/

/
/
4:15pm/
4:15pm/

4:15pm/

use.
Inform OR before transport / / 4:15pm/

Tancinco, Don B.
09/02/2021
Dr. Macapolot

C – Carried A – Administered R – Requested E – Endorsed D – Discontinued

Effectivity Date: 03/04/2020 REV. No.: 01 GCGMH-F-HIM-50

 This form is used for educational purposes only and with approval from the concerned agency. Strictly not for reproduction.

Ward / Room: ________

DOCTOR’S ORDER/NURSE’S COMPLIANCE SHEET
(Authenticate All Orders)
Time Posted
Signature
C A R E D
Date, Time &
Notes ORDER
/

NOT FOR
REPRODUCTION
C – Carried A – Administered R – Requested E – Endorsed D – Discontinued

Effectivity Date: 03/04/2020 REV. No.: 01 GCGMH-F-HIM-50

This form is used for educational purposes only and with approval from the concerned agency. Strictly not for reproduction.