Substance Abuse
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PHYSICIAN'S ORDER SHEET Substance Abuse Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated.
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patient imprint
Allergies: ___________________ Admission Status g Admit to inpatient to Dr. _______ service. c d e f c Admit to observation to Dr. _________ service. d e f g Admission Location c Admit to locked unit d e f g c Admit to unlocked unit d e f g
Code Status g Resuscitation status Full Code c d e f c Resuscitation status Do Not Resuscitate / Do Not d e f g Intubate (allow natural death) c Resuscitation status Partial Code d e f g Vital Signs c Vitals per unit protocol d e f g c Vital signs with neuro checks every _______ hour. d e f g Activity Level 1 (every 15 minute rounding) c Homicidal d e f g c Suicidal d e f g c Elopement d e f g c Safety d e f g Level 2 (Close observation) c Homicidal d e f g c Suicidal d e f g c Elopement d e f g c Safety d e f g Level 3 (arm's length) c Homicidal d e f g c Suicidal d e f g c Elopement d e f g c Safety d e f g c ad lib d e f g
Nursing Orders Assessments c Assess pain d e f g c Cardiac monitor Evidence d e f g Contingency c Notify provider temp > 101; HR < 60 or > 120; RR > d e f g 30; BP , 90 or > 180; bs > 450; uo < 120 ML/ 4 HR. Interventions c Peripheral venous cannula insertion/management d e f g Respiratory c Oxygen via nasal cannula d e f g c Pulse oximetry Evidence d e f g Diet c Clear liquid diet d e f g c Regular diet d e f g c Therapeutic diet _______ d e f g
IV Fluids c Dextrose 5% with 0.45% NaCl @ _____mL/hr for 24 d e f g hours. c Dextrose 5% with 0.9% NaCl @ _____mL/hr for 24 d e f g hours. c Sodium Chloride 0.9% @ _____mL/hr for 24 hours. d e f g c Sodium Chloride 0.9% 1000 cc with 2 G magnesium d e f g sulfate plus 1 mg folic acid plus 1 amp MVI, 100mg Thiamine @ _____mL/hr for 24 hours. c Dextrose 5% with 0.45% NaCl 1000 mL with 2 G d e f g magnesium sulfate plus 1 mg folic acid plus 1 amp MVI, 100mg Thiamine @ _____mL/hr for 24 hours. c Additives d e f g
Medications g Opiate Abuse c d e f Opioid Agonists c methadone /DOLOPHINE 15 mg orally then give 5 mg d e f g orally every 2 hours as needed to a maximum of 40 mg on day 1 c buprenorphine /BUPRENEX 4 mg SL at onset of d e f g withdrawal and 2 mg SL in the evening as needed c buprenorphine /BUPRENEX 4 mg SL at onset of d e f g withdrawal and 4 mg SL in the evening as needed c buprenorphine/naloxone/SUBOXONE 4 mg now and d e f g may repeat in 2 hours (maximum of 8 mg on day 1 and max of 16 mg day 2) ( Must be certified to use) Any nonlicensed facility methadone use for opiate withdrawal must be completed within 72 hr. c natrexone/REVIA 25 mg po. Repeat in 1 hr. if no d e f g withdrawal and start on 50 mg po qd Nonopioid agonists c cloNIDine /CATAPRES 0.2 milligram orally 3 times a d e f g day c cloNIDine /CATAPRES 0.1 milligram orally every 4 d e f g hours PRN c lofexidene /BRITOFLEX 0.2 mg orally twice a day d e f g Cocaine and stimulant abuse Benzodiazepines Evidence c diazepam /VALIUM 5 milligram orally every 6 hours d e f g c diazepam /VALIUM 10 milligram orally every 6 hours d e f g c diazepam /VALIUM 5 milligram intravenously every 6 d e f g hours as needed for agitiation c LORazepam /ATIVAN 1 milligram orally every 6 hours d e f g c LORazepam /ATIVAN 2 milligram orally every 6 hours d e f g c LORazepam /ATIVAN 2 milligram intravenously every d e f g 6 hours as needed for agitation c LORazepam /ATIVAN 2 milligram intramuscularly d e f g every 6 hours as needed for agitation
Order Initiated By: _________________________ Date/Time: _______________ Physician Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: April 2, 2009 Page &p of &P
PHYSICIAN'S ORDER SHEET
patient imprint
Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated. c LORazepam /ATIVAN 2 milligram intramuscularly d e f g c haloperidol 5 mg IM every 4 hours as needed for d e f g every 2 hours as needed for agitation behavioral control c LORazepam /ATIVAN __mg __orally or d e f g c ziprasidone/GEODON 20 mg IM now for behavioral d e f g __intramuscularly every ___hours as needed for control agitation Antiemetics c oxazepam /SERAX 15 milligram orally 3 times a day d e f g c metoclopramide /REGLAN 10 milligram intravenously d e f g BetaBlockers Evidence every 6 hours as needed for nausea/vomiting c atenolol /TENORMIN 50 milligram orally once a day d e f g c metoclopramide /REGLAN 10 milligram orally every 6 d e f g hours as needed for nausea/vomiting c atenolol /TENORMIN 100 milligram orally once a day d e f g c promethazine/PHENERGAN 25 mg IM every 6 hours as d e f g c propranolol /INDERAL 40 mg orally twice a day d e f g needed for nausea and vomiting Benzodiazepine abuse c promethazine/PHENERGAN 25 mg suppository PR d e f g c hydrOXYzine /VISTARIL 50 mg po/IM q4h prn for d e f g every 6 hours as needed for nausea and vomiting agitation Barbiturates c promethazine/PHENERGAN 12.5 mg in 50 mL of saline d e f g slow IVP every 6 hours as needed for nausea and c PHENobarbital 30 mg orally 4 times a day d e f g vomiting c PHENobarbital 30mg orally or IM every 2hours PRN for d e f g Antidiarrheals agitation Benzodiazepines Evidence c loperamide/IMODIUM 4 mg now and 2 mg orally after d e f g each loose BM not to exceed 16 mg/day c diazepam /VALIUM 5 milligram orally every 6 hours d e f g Analgesics/Antispasmodics c diazepam /VALIUM 10 milligram orally every 6 hours d e f g c acetaminophen 650 mg tab /TYLENOL every 4 hours d e f g c diazepam /VALIUM 5 milligram intravenously every 6 d e f g orally as needed for mild (13) pain hours as needed for agitiation ibuprofen/MOTRIN 400 mg tab orally every 6 hours as c d e f g LORazepam /ATIVAN 1 milligram orally every 6 hours c d e f g needed for mild (13) pain c LORazepam /ATIVAN 2 milligram orally every 6 hours d e f g ketorolac/TORADOL 30mg IM every 6 hours as c d e f g c LORazepam /ATIVAN 2 milligram intravenously every d e f g needed for mild (13) pain 6 hours as needed for agitation dicyclomine/BENTYL 20 mg IM every 6 hours as c d e f g c LORazepam /ATIVAN 2 milligram intramuscularly d e f g needed for abdominal pain every 6 hours as needed for agitation Vitamins c LORazepam /ATIVAN 2 milligram intramuscularly d e f g Vitamin B Preparations Evidence every 2 hours as needed for agitation c folic acid /VITAMIN B9 1 milligram orally or d e f g c oxazepam /SERAX 15 milligram orally 3 times a day d e f g intramuscularly once a day Hallucinogenic abuse thiamine /VITAMIN B1 100 milligram orally or c d e f g Benzodiazepines Evidence intramuscularly once a day c diazepam /VALIUM 5 milligram orally every 6 hours d e f g neurecover 2 capsules tid c d e f g c diazepam /VALIUM 10 milligram orally every 6 hours d e f g multivitamin 1 po bid c d e f g diazepam /VALIUM 5 milligram intravenously every 6 c d e f g Laboratory hours as needed for agitiation Chemistry c LORazepam /ATIVAN 1 milligram orally every 6 hours d e f g c Calcium Level, total d e f g c LORazepam /ATIVAN 2 milligram orally every 6 hours d e f g c Glucose, serum, random d e f g c LORazepam /ATIVAN 2 milligram intravenously every d e f g c Vitamin B12 level d e f g 6 hours as needed for agitation c Folate level d e f g c LORazepam /ATIVAN 2 milligram intramuscularly d e f g every 6 hours as needed for agitation c Magnesium (Mg) d e f g c Ammonia, plasma d e f g c LORazepam /ATIVAN 2 milligram intramuscularly d e f g every 2 hours as needed for agitation c CPK d e f g Hematology c oxazepam /SERAX 15 milligram orally 3 times a day d e f g Antipsychotics c Complete blood cell count with automated white blood d e f g cell differential c haloperidol /HALDOL 5 mg orally every 4 hours as d e f g needed for behavioral control c Prothrombin time (PT) and international normalized d e f g ratio (INR) Order Initiated By: _________________________ Date/Time: _______________ Physician Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: April 2, 2009 Page &p of &P
PHYSICIAN'S ORDER SHEET Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated. Panels c Basic metabolic panel d e f g c Comprehensive metabolic panel d e f g c Hepatic function panel d e f g Serology c tuberculin ppd 5 unit/0.1 ml intradermal d e f g c Hepatitis panel, acute d e f g c Rapid HIV1 antibodies, qualitative, POC d e f g c Rapid plasma reagin (RPR), qualitative d e f g Toxiclogy c Toxicology drug screen, urine d e f g c Serum drug screen d e f g Consults c Consult to hospitalist d e f g c Consult to neurology d e f g c Consult to psychiatry d e f g c Consult individual therapist d e f g
patient imprint
Other: ___________________________
Order Initiated By: _________________________ Date/Time: _______________ Physician Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: April 2, 2009 Page &p of &P
Print Only Selected Items
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PHYSICIAN'S ORDER SHEET Substance Abuse Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated.
Print All
patient imprint
Allergies: ___________________ Admission Status g Admit to inpatient to Dr. _______ service. c d e f c Admit to observation to Dr. _________ service. d e f g Admission Location c Admit to locked unit d e f g c Admit to unlocked unit d e f g
Code Status g Resuscitation status Full Code c d e f c Resuscitation status Do Not Resuscitate / Do Not d e f g Intubate (allow natural death) c Resuscitation status Partial Code d e f g Vital Signs c Vitals per unit protocol d e f g c Vital signs with neuro checks every _______ hour. d e f g Activity Level 1 (every 15 minute rounding) c Homicidal d e f g c Suicidal d e f g c Elopement d e f g c Safety d e f g Level 2 (Close observation) c Homicidal d e f g c Suicidal d e f g c Elopement d e f g c Safety d e f g Level 3 (arm's length) c Homicidal d e f g c Suicidal d e f g c Elopement d e f g c Safety d e f g c ad lib d e f g
Nursing Orders Assessments c Assess pain d e f g c Cardiac monitor Evidence d e f g Contingency c Notify provider temp > 101; HR < 60 or > 120; RR > d e f g 30; BP , 90 or > 180; bs > 450; uo < 120 ML/ 4 HR. Interventions c Peripheral venous cannula insertion/management d e f g Respiratory c Oxygen via nasal cannula d e f g c Pulse oximetry Evidence d e f g Diet c Clear liquid diet d e f g c Regular diet d e f g c Therapeutic diet _______ d e f g
IV Fluids c Dextrose 5% with 0.45% NaCl @ _____mL/hr for 24 d e f g hours. c Dextrose 5% with 0.9% NaCl @ _____mL/hr for 24 d e f g hours. c Sodium Chloride 0.9% @ _____mL/hr for 24 hours. d e f g c Sodium Chloride 0.9% 1000 cc with 2 G magnesium d e f g sulfate plus 1 mg folic acid plus 1 amp MVI, 100mg Thiamine @ _____mL/hr for 24 hours. c Dextrose 5% with 0.45% NaCl 1000 mL with 2 G d e f g magnesium sulfate plus 1 mg folic acid plus 1 amp MVI, 100mg Thiamine @ _____mL/hr for 24 hours. c Additives d e f g
Medications g Opiate Abuse c d e f Opioid Agonists c methadone /DOLOPHINE 15 mg orally then give 5 mg d e f g orally every 2 hours as needed to a maximum of 40 mg on day 1 c buprenorphine /BUPRENEX 4 mg SL at onset of d e f g withdrawal and 2 mg SL in the evening as needed c buprenorphine /BUPRENEX 4 mg SL at onset of d e f g withdrawal and 4 mg SL in the evening as needed c buprenorphine/naloxone/SUBOXONE 4 mg now and d e f g may repeat in 2 hours (maximum of 8 mg on day 1 and max of 16 mg day 2) ( Must be certified to use) Any nonlicensed facility methadone use for opiate withdrawal must be completed within 72 hr. c natrexone/REVIA 25 mg po. Repeat in 1 hr. if no d e f g withdrawal and start on 50 mg po qd Nonopioid agonists c cloNIDine /CATAPRES 0.2 milligram orally 3 times a d e f g day c cloNIDine /CATAPRES 0.1 milligram orally every 4 d e f g hours PRN c lofexidene /BRITOFLEX 0.2 mg orally twice a day d e f g Cocaine and stimulant abuse Benzodiazepines Evidence c diazepam /VALIUM 5 milligram orally every 6 hours d e f g c diazepam /VALIUM 10 milligram orally every 6 hours d e f g c diazepam /VALIUM 5 milligram intravenously every 6 d e f g hours as needed for agitiation c LORazepam /ATIVAN 1 milligram orally every 6 hours d e f g c LORazepam /ATIVAN 2 milligram orally every 6 hours d e f g c LORazepam /ATIVAN 2 milligram intravenously every d e f g 6 hours as needed for agitation c LORazepam /ATIVAN 2 milligram intramuscularly d e f g every 6 hours as needed for agitation
Order Initiated By: _________________________ Date/Time: _______________ Physician Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: April 2, 2009 Page &p of &P
PHYSICIAN'S ORDER SHEET
patient imprint
Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated. c LORazepam /ATIVAN 2 milligram intramuscularly d e f g c haloperidol 5 mg IM every 4 hours as needed for d e f g every 2 hours as needed for agitation behavioral control c LORazepam /ATIVAN __mg __orally or d e f g c ziprasidone/GEODON 20 mg IM now for behavioral d e f g __intramuscularly every ___hours as needed for control agitation Antiemetics c oxazepam /SERAX 15 milligram orally 3 times a day d e f g c metoclopramide /REGLAN 10 milligram intravenously d e f g BetaBlockers Evidence every 6 hours as needed for nausea/vomiting c atenolol /TENORMIN 50 milligram orally once a day d e f g c metoclopramide /REGLAN 10 milligram orally every 6 d e f g hours as needed for nausea/vomiting c atenolol /TENORMIN 100 milligram orally once a day d e f g c promethazine/PHENERGAN 25 mg IM every 6 hours as d e f g c propranolol /INDERAL 40 mg orally twice a day d e f g needed for nausea and vomiting Benzodiazepine abuse c promethazine/PHENERGAN 25 mg suppository PR d e f g c hydrOXYzine /VISTARIL 50 mg po/IM q4h prn for d e f g every 6 hours as needed for nausea and vomiting agitation Barbiturates c promethazine/PHENERGAN 12.5 mg in 50 mL of saline d e f g slow IVP every 6 hours as needed for nausea and c PHENobarbital 30 mg orally 4 times a day d e f g vomiting c PHENobarbital 30mg orally or IM every 2hours PRN for d e f g Antidiarrheals agitation Benzodiazepines Evidence c loperamide/IMODIUM 4 mg now and 2 mg orally after d e f g each loose BM not to exceed 16 mg/day c diazepam /VALIUM 5 milligram orally every 6 hours d e f g Analgesics/Antispasmodics c diazepam /VALIUM 10 milligram orally every 6 hours d e f g c acetaminophen 650 mg tab /TYLENOL every 4 hours d e f g c diazepam /VALIUM 5 milligram intravenously every 6 d e f g orally as needed for mild (13) pain hours as needed for agitiation ibuprofen/MOTRIN 400 mg tab orally every 6 hours as c d e f g LORazepam /ATIVAN 1 milligram orally every 6 hours c d e f g needed for mild (13) pain c LORazepam /ATIVAN 2 milligram orally every 6 hours d e f g ketorolac/TORADOL 30mg IM every 6 hours as c d e f g c LORazepam /ATIVAN 2 milligram intravenously every d e f g needed for mild (13) pain 6 hours as needed for agitation dicyclomine/BENTYL 20 mg IM every 6 hours as c d e f g c LORazepam /ATIVAN 2 milligram intramuscularly d e f g needed for abdominal pain every 6 hours as needed for agitation Vitamins c LORazepam /ATIVAN 2 milligram intramuscularly d e f g Vitamin B Preparations Evidence every 2 hours as needed for agitation c folic acid /VITAMIN B9 1 milligram orally or d e f g c oxazepam /SERAX 15 milligram orally 3 times a day d e f g intramuscularly once a day Hallucinogenic abuse thiamine /VITAMIN B1 100 milligram orally or c d e f g Benzodiazepines Evidence intramuscularly once a day c diazepam /VALIUM 5 milligram orally every 6 hours d e f g neurecover 2 capsules tid c d e f g c diazepam /VALIUM 10 milligram orally every 6 hours d e f g multivitamin 1 po bid c d e f g diazepam /VALIUM 5 milligram intravenously every 6 c d e f g Laboratory hours as needed for agitiation Chemistry c LORazepam /ATIVAN 1 milligram orally every 6 hours d e f g c Calcium Level, total d e f g c LORazepam /ATIVAN 2 milligram orally every 6 hours d e f g c Glucose, serum, random d e f g c LORazepam /ATIVAN 2 milligram intravenously every d e f g c Vitamin B12 level d e f g 6 hours as needed for agitation c Folate level d e f g c LORazepam /ATIVAN 2 milligram intramuscularly d e f g every 6 hours as needed for agitation c Magnesium (Mg) d e f g c Ammonia, plasma d e f g c LORazepam /ATIVAN 2 milligram intramuscularly d e f g every 2 hours as needed for agitation c CPK d e f g Hematology c oxazepam /SERAX 15 milligram orally 3 times a day d e f g Antipsychotics c Complete blood cell count with automated white blood d e f g cell differential c haloperidol /HALDOL 5 mg orally every 4 hours as d e f g needed for behavioral control c Prothrombin time (PT) and international normalized d e f g ratio (INR) Order Initiated By: _________________________ Date/Time: _______________ Physician Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: April 2, 2009 Page &p of &P
PHYSICIAN'S ORDER SHEET Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated. Panels c Basic metabolic panel d e f g c Comprehensive metabolic panel d e f g c Hepatic function panel d e f g Serology c tuberculin ppd 5 unit/0.1 ml intradermal d e f g c Hepatitis panel, acute d e f g c Rapid HIV1 antibodies, qualitative, POC d e f g c Rapid plasma reagin (RPR), qualitative d e f g Toxiclogy c Toxicology drug screen, urine d e f g c Serum drug screen d e f g Consults c Consult to hospitalist d e f g c Consult to neurology d e f g c Consult to psychiatry d e f g c Consult individual therapist d e f g
patient imprint
Other: ___________________________
Order Initiated By: _________________________ Date/Time: _______________ Physician Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: April 2, 2009 Page &p of &P
Print Only Selected Items
Print All
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