Ministry of Defense ‫وزارة الـــدفـــــاع‬

‫اسم المريض‬ Logistics Authority of Armed Forces ‫هيئة االمداد والتموين‬

Armed Forces Medical Services ‫ادارة الخدمات الطبية‬
‫الرقم الطبي‬ Hospital / / ‫مستشفي‬

Spinal Anesthesia Preprinted Order

Pre-Operative Drug Name Dose Route Direction Frequency

Number Verify 1st time 2nd time 3rd time

1 o Heavy Marcain Intra-

20mg/4ml amp thecal

1 o Xylocain 2% 2ml Amp Local

2 o Ephedrine 30mg /ml IV

1 o Atropine1mg/ml amp IV

Other drugs

Physician
Sign

Date

Anesthesia physician name & sign: ………………….………………… Pharmacist Sign: …………………

Given by ( name ) :……………………………….................................. Date :……………………………

 Ministry of Defense ‫وزارة الـــدفـــــاع‬
‫اسم المريض‬ Logistics Authority of Armed Forces ‫هيئة االمداد والتموين‬
Armed Forces Medical Services ‫ادارة الخدمات الطبية‬
‫الرقم الطبي‬ Hospital / / ‫مستشفي‬

Epidural Anesthesia Preprinted Order

Pre-Operative Drug Name Dose Route Direction Frequency

Number Verify 1st time 2nd time 3rd time

1 o Marcain 100*20ml vial Cath

1 o Xylocain 2% 2ml Amp Cath

2 o Ephedrine 30mg /ml IV

1 o Atropine1mg/ml amp IV

Other drugs

Physician
Sign

Date

Anesthesia physician name & sign: ………………….………………… Pharmacist Sign: …………………

Given by ( name ) :……………………………….................................. Date :…………………………… …

 Ministry of Defense ‫وزارة الـــدفـــــاع‬
‫اسم المريض‬ Logistics Authority of Armed Forces ‫هيئة االمداد والتموين‬
Armed Forces Medical Services ‫ادارة الخدمات الطبية‬
‫الرقم الطبي‬ Hospital / / ‫مستشفي‬

General Anesthesia Preprinted Order

Pre-Operative Drug Name Dose Route Direction Frequency

Number Verify 1st time 2nd time 3rd time

1 o Diprivan 200mg amp IV

2 o Tracium 50 mg/Amp. IV
OR

2 o Esmeron 50 mg /Vial IV

1 o Succinyl choline 100mg IV

Amp.

1 o Prostigmine 12.5mg/5ml IV
vial

2 o Atropie 1mg/ml amp IV

2 o Ephedrine30mg /ml IV

2 o Ketolac 30 mg

1 o Dexamethazon IV

Other drugs

Physician
sign
Date
Anesthesia physician name & sign: ………………….………………… Pharmacist Sign:…………………

Given by ( name ) :……………………………….................................. Date :……………………………

 Ministry of Defense ‫وزارة الـــدفـــــاع‬
‫اسم المريض‬ Logistics Authority of Armed Forces ‫هيئة االمداد والتموين‬
Armed Forces Medical Services ‫ادارة الخدمات الطبية‬
‫الرقم الطبي‬ Hospital / / ‫مستشفي‬

Open Heart Anesthesia Preprinted Order

Anesthesia physician sign:…………………. Pharmacist Sign:………………………..
Date :………………………………………... Given by:………………………………...
Pre-Operative Drug Name Dose Route Direction Frequency

Number Verify 1st time 2nd time 3rd time

2 o Diprivan 200mg amp IV

6 o Tracium 50 mg/Amp IV

1 o Tiopental vial IV

4 o Pancuranium amp IV

1 o Tridil 50mg/50ml vial IV

9 o Heparin 5000u/ml IV

1 o Protamine vial IV

2 o Atropie 1mg/ml amp

2 o Ephedrine 30mg /ml

4 o Adrenaline

Other drugs
Nor adrenaline

Dobutammie

Lasix 40mg /4 ml

Morphine 20 mg

Fentanyl 100 ug

Magnesium Sulphate
 Ministry of Defense ‫وزارة الـــدفـــــاع‬
‫اسم المريض‬ Logistics Authority of Armed Forces ‫هيئة االمداد والتموين‬
Armed Forces Medical Services ‫ادارة الخدمات الطبية‬
‫الرقم الطبي‬ Hospital / / ‫مستشفي‬

Calcium chloride

Calcium Gluconate

Potassium Chloride

Amiodarone

Xylocaine Vial 2%

Physician
Sign

Date

Anesthesia physician name & sign: ………………….………………… Pharmacist Sign:……………………

Given by ( name ) :……………………………….................................. Date :……………………………