Gulliver's Travel
Applicable to Surgery, IM, OB For Pedia, ask your resident DO NOT WRITE text in RED (comments only)
Date/Time 4/1/13 930 AM
Transfer out order (from Recovery Room) S-O-A-P ORDERS T-36.2 P-80 RR-18 BP-100/70 May transfer out patient back to room (-) Headache (-) vomiting Discontinue O2 and pulse oximeter For spinal anesthesia: Monitor vital signs q hourly until stable (+) able to flex both knees MIO q hour and record; refer urine output less than 30 cc/hr Watch out for any untoward s/sx such as hypotension and bleeding Refer accordingly Thank you. signature Dr. Resident(Surname)/JI(Surname)
Date/Time 4/2/13 7 PM
Cardiopulmonary Status (CP Status) for blood transfusion S-O-A-P ORDERS T-36.6 P-80 RR-18 BP-110/70 CP status assessed Clear breath sounds, symmetrical May transfuse available unit of PRBC of patient’s chest expansion; (-) dyspnea blood type after crossmatching to run for 4 hours (-) DOB; adynamic precordium Initially run 15-25 drops/min and titrate if without optional regular rate and rhythm BT reactions Mainline to KVO while on BT Vital signs q15 minutes for the 1st hour then q hourly if without BT reactions Watch out for BT reactions such as fever, tachycardia, tachypnea, rashes, pulmonary congestion Refer accordingly Thank you signature Dr. Resident(Surname)/JI(Surname)
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Skin Test Interpretation Date/Time 4/3/13 340 PM S-O-A-P
Time skin test was read
ORDERS NST to Cefuroxime (Zegen) signature Dr. Resident(Surname)/JI(Surname) *NST – negative skin test
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IV Follow up Date/Time S-O-A-P ORDERS 1. Note that drops/min (gtts/min), microdrops/min (ugtts/min), and cc/hour may differ. Take note! 2. Some patients have alternating IV fluids e.g. DsLR then D5NM then D5LR again. 3. Ask the nurse in charge when you’re not sure. 4. Pedia interns: Pediatric patients are very prone to fluid overload if you order the wrong rate. Be careful. IVF to ff: D5LR 1L x 125cc/hr signature Dr.
Date/Time 4/1/13 930 AM
Transfer out order (from Recovery Room) S-O-A-P ORDERS T-36.2 P-80 RR-18 BP-100/70 May transfer out patient back to room (-) Headache (-) vomiting Discontinue O2 and pulse oximeter For spinal anesthesia: Monitor vital signs q hourly until stable (+) able to flex both knees MIO q hour and record; refer urine output less than 30 cc/hr Watch out for any untoward s/sx such as hypotension and bleeding Refer accordingly Thank you. signature Dr. Resident(Surname)/JI(Surname)
Date/Time 4/2/13 7 PM
Cardiopulmonary Status (CP Status) for blood transfusion S-O-A-P ORDERS T-36.6 P-80 RR-18 BP-110/70 CP status assessed Clear breath sounds, symmetrical May transfuse available unit of PRBC of patient’s chest expansion; (-) dyspnea blood type after crossmatching to run for 4 hours (-) DOB; adynamic precordium Initially run 15-25 drops/min and titrate if without optional regular rate and rhythm BT reactions Mainline to KVO while on BT Vital signs q15 minutes for the 1st hour then q hourly if without BT reactions Watch out for BT reactions such as fever, tachycardia, tachypnea, rashes, pulmonary congestion Refer accordingly Thank you signature Dr. Resident(Surname)/JI(Surname)
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Skin Test Interpretation Date/Time 4/3/13 340 PM S-O-A-P
Time skin test was read
ORDERS NST to Cefuroxime (Zegen) signature Dr. Resident(Surname)/JI(Surname) *NST – negative skin test
(
IV Follow up Date/Time S-O-A-P ORDERS 1. Note that drops/min (gtts/min), microdrops/min (ugtts/min), and cc/hour may differ. Take note! 2. Some patients have alternating IV fluids e.g. DsLR then D5NM then D5LR again. 3. Ask the nurse in charge when you’re not sure. 4. Pedia interns: Pediatric patients are very prone to fluid overload if you order the wrong rate. Be careful. IVF to ff: D5LR 1L x 125cc/hr signature Dr.