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Blank Order Form
Blank Order Form
Anesthesia Orders
Adult Anesthesia PACU (Low Dose) Plan
Adult Anesthesia Post-Op PACU Plan
Adult Anesthesia Post-Op Outpatient Surgery Plan
Anesthesia Continuous Epidural Plan
Anesthesia Epidural/Intrathecal Post-OP Plan
Anesthesia Post-Op Oxygen-Pulse Ox Plan
Anesthesia Pre-Op and OR Holding Plan
Pediatric Anesthesia Post-Op PACU Plan
Pediatric Anesthesia Post-Op Outpatient Surgery Plan
Bariatric Orders
Bariatric Surgery Pre-Op Plan
Bariatric Surgery Post-Op Plan
BICU Orders
Beta Blocker Therapy for Burn Metabolism Plan
BICU Post-Tramatic Stress Disorder Med Plan
Burn Integra Orders
Pediatric Beta Blocker Therapy for Burn Metabolism Plan
Vitamin C Resuscitation Plan
Cardiac Orders
Chest Pain Plan
CV Surgery Insulin Protocol Plan
Dobutamine Echo
Electrophysiology Study Plan
Heart Failure Plan
Hypothermia Guidelines Post Cardiac Arrest
Implantable Device Plan
Open Heart Immediate Post-Op Plan
Open Heart POD1 - POD3 Plan
Open Heart Pre-Op Plan
Outpatient Implantable Device Plan or Generator Change Out Plan
Outpatient Pre-Op Cardiac Cath Plan
Outpatient Pre-Cardiovascular Procedure Plan
Post Cardiac Catheterization Plan
Post Peripheral Cath Orders
Radial Artery Compression Device Removal Orders
Therapeutic Hypothermia for Post-Cardiac Arrest Plan
Thoracotomy Post-Op Plan
Thoracotomy Pre-Op Plan
Tilt Table Test
Transcatheter Aortic Valve Replacement Post-Op Plan
Chemotherapy Orders
Adult Chemotherapy Plan
Dialysis Orders
CAPD Exchange Orders Form
Continuous Ambulatory Peritoneal Dialysis Plan (CAPD)
Continuous Renal Replacement Therapy Plan (CRRT)
CRRT Sliding Scale for ACDA and Calcium Infusion
Dianeal 2.5 with cefepime 1g Nightly
Dianeal 2.5 with cefepime 1g Nightly + vancomycin 1g every 4th Night
Dianeal 2.5 with cefTAZidime 1g Nightly
Dianeal 2.5 with cefTAZidime 1g Nightly + vancomycin 1g every 4th Night
Dianeal 2.5 with vancomycin 1g every 4th Night
Dianeal Alternating Solution Regimen
Hemodialysis Exchange Orders
Hemodialysis Plan
Discharge Orders
Adult Discharge Plan
Pediatric Discharge Plan
ECMO/Mechanical Heart Orders
Adult ECMO
Adult ECMO Heparin Infusion Guidelines
Behavioral Contingency Contract for Mechanical Circulatory Support Candidates
CARD-LVAD Antimicrobial Bath Preparation
CARD-LVAD Discharge Planner Check Sheet
CARD-LVAD Driveline Dressing Change-IP (Covaderm)
CARD-LVAD Driveline Dressing Change-OP (24 hr) (Chloraprep)
CARD-LVAD Driveline Dressing Change-OP (Covaderm)
CARD-LVAD Driveline Dressing Change-OP (Weekly) Chloraprep
CARD-LVAD Epistaxis Protocol Inpatient
CARD-LVAD Epistaxis Protocol Outpatient
CARD-LVAD Evaluation for Destination Therapy (Emergent 6 hr)
CARD-LVAD Post Extubation Plan
CARD-LVAD Post Op Plan
Mechanical Heart Program Evaluation
Emergency Dept Orders
SANE Standing Delegation Orders
Endoscopy Outpatient
Fecal Microbiota Donor Screening
Fecal Microbiota Trasplant Plan
Fecal Microbiota Transplant Donor Questionnaire
Fecal Microbiota Specimen Processing
Inpatient Endoscopy Procedure Plan
Outpatient Endoscopy Procedure Plan
Outpatient Endoscopy (GI) Procudre Plan
Outpatient Endoscopy (Pain) Procedure Plan
Outpatient Endoscopy (Pulm) Procedure Plan
Fecal Microbiota Transplant Reference Sheet
Transoral Incisionless Fundoplication (TIF) Post-Op Plan
Inpatient Orders
Admit Plan
Comfort Care Plan
ENT Thyroidectomy/Parathyroidectomy Post Op Plan
General Medicine Plan
General Surgery Inpatient Pre-Op Plan
General Surgery Plan
General Surgery Post-Op Plan
Geriatric Trauma Plan
GI Bleed Plan
Lysis of Adhesions Post-Op Plan
Newborn General Plan
Pneumonia Plan
Sepsis Plan
Snakebite Plan
Surgery Burn Plan
Trauma and Surgical ICU Plan
LifeGift Orders
Donation After Cardiac Death Plan
LifeGift Brain Death Plan
Pediatric LifeGift Brain Death Plan
Adult Bowel Program Plan
Adult Enteral Nutrition Guidelines
Adult Splenectomy Vaccine Plan
Alcohol Withdrawlal Syndrome Plan
Anticoagulation Reversal Plan
Argatroban Orders for Heparin Induced Thrombocytopenia
Clostridium Difficile Infection (CDI) Plan
Concentrated Infusions Med Plan
Diabetic Ketoacidosis (DKA) Plan
Discomfort Med Plan
Dofetilide (Tikosyn) Initiation Orders
Electrolyte Med Plan
Ethanol Lock for Central IV Catheter Plan
Heparin Infusion Guidelines
Heparin Infusion Med Plan
Hypoglycemia Protocol Plan
ICU Epoetin ALFA (Procrit) Plan
ICU Paralytic Plan
ICU Sedation and Pain Med Plan
Insulin Drip Plan
Low Molecular Weight Heparin Guidelines
Methylprednisolone (Solu-Medrol) for Spinal Cord Injury Plan
Parenteral Nutrition Plan
PCA Med Plan
Sliding Scale Insulin Aspart Plan
Sliding Scale Insulin Protocol Plan
VTE Prophylaxis Plan
Warfarin Guidelines
NICU Orders
Neonatal/Pediatric Parenteral Nutrition Formulation
NICU Continuous Infusion Med Plan
NICU Delivery Plan
NICU Discharge Plan
NICU Discharge Social Services Plan
NICU General Plan
NICU Intubation for Procedure Plan
NICU Necrotizing Enterocolitis Plan
NICU Nutrition Plan
NICU Parenteral Nutrition Plan
NICU Procedure Plan
NICU Respiratory Plan
NICU ROP Exam Plan
NICU ROP Post Treatment Plan
NICU Sedation and Pain Med Plan
NICU Transport Plan
Neuro Orders
External Ventricular Drain Plan
IV Acetaminophen Pain Study for Neurosurgery Post-Op Non ICU Plan
Neurointervention Plan
Neurosurgery ICU Plan
Neurosurgery Non ICU Plan
Post Neurointervention Plan
Stroke Neurointervention Plan
OB/GYN Orders
Antepartum Plan
Cesarean Pre-Op Plan
Cesarean Post-Op Discomfort Plan - Analgesics Sedatives Antiemetics Antihistamines
Cesarean Post-Op Discomfort Plan - NonAnalgesics NonSedating Only
Cesearean Section Post-Op Plan
General Post Op Plan
General Pre-Op Op Plan
GYN General Plan
GYN ONC Post-Op Plan
High Dose Oxytocin Administration Plan
Intrapartum Insulin Infusion Plan
Intrapartum Plan
Labor and Delivery Anesthesia Epidural Intrathecal Post-Op Plan
Labor and Delivery Epidural Plan
Labor and Delivery Epidural Post Op Plan
Magnesium Sulfate Administration Plan
Postpartum Vaginal Delivery Plan
Outpatient Surgery Orders
Adult Outpatient Ophthalmology Plan
Adult Outpatient Surgery Plan
Adult Outpatient Surgery Post-Op Discomfort Med Plan
EC OR Adult Outpatient Surgery Plan
EC OR Pediatric Outpatient Surgery Plan
GYN ONC Outpatient Surgery Plan
Miscarriage Orders Pre-Op Plan
Outpatient BB Type and Screen
Outpatient Ophthalmology Pre-Visit Lab Plan
Outpatient Radiology with Sedation Plan
Outpatient Radiology with General Anesthesia Plan
Outpatient Transfusion Plan
Outpatient Ultrasound Guided Oocyte retrieval Plan - Day of Procdure Pre-Op Orders
PACU Post-Op Diagnostic Tests
Pediatric Outpatient Surgery Plan
Pediatric Outpatient Surgery Post-Op Med Discomfort Plan
Pediatric Outpatient Ophthalmology Plan
PICC Line Placement
Orthopedics Orders
General Ortho Plan
Orthopedics Consult Pre-Op
Orthopedics General Post-Op
Orthopedics Hemiarthroplasty/Open Reduction Internal Fixation Hip Post-Op Plan
Orthopedics Post-Op Plan
Ortho Post-Op Medication Plan
Orthopedics Total Hip Replacement Post-Op Plan
Orthopedics Total Knee Replacement Post-Op Plan
Pediatrics/PICU Orders
Pediatric Anticoagulant Plan
Pediatric Arginine Clonidine Stimulation Test Plan
Pediatric Asthma Plan
Pediatric Bronchiolitis Plan
Pediatric Burn Plan
Pediatric Alteplase Injection for CVL Plan
Pediatric Central IV Flush Plan
Pediatric Craniotomy Post-Op Plan
Pediatric Cystic Fibrosis Plan
Pediatric Diabetes Plan
Pediatric Endoscopic Third Ventriculostomy Post-Op Plan
Pediatric Facial Plastic Post-Op Plan
Pediatric GI Plan
Pediatric General Plan
Pediatric Insulin Dosing Plan
Pediatric Laminectomy Post-Op Plan
Pediatric Neurosurgery Pre-Op Plan
Pediatric Opiate Wean Plan
Pediatric Parenteral Nutrition Plan
Pediatric PICC Insertion Plan
Pediatric Shunt Placement Revision Post Op Plan
Pediatric Spin Surgery Post-Op Plan
Pediatric Surgery Post-Op Plan
Pediatric Surgery Pre-Op Plan
Pediatric Tonsillectomy & Adenoidectomy Post-Op Plan
PICU Bronchiolitis Plan
PICU CNS Failure Plan
PICU CV Failure Plan
PICU Continuous Med Infusion Plan
PICU Encephalopathy Plan
PICU Enteral Nutrition Plan
PICU General Plan
PICU Therapeutic Hypothermia Post Cardiac Arrest Plan
PICU Hypothermia Guidelines Post Cardiac Arrest
PICU Mechanical Ventilation And Neuromuscular Blockade Plan
PICU Peritoneal Dialysis Plan
PICU Procedure Plan
PICU Procedural Sedation Med Plan
PICU Respiratory Failure Plan
Pediatrics/PICU Trauma Orders
Pediatric Liver and Spleen Injury Plan
Pediatric Non-Accidental Trauma Plan
Pediatric Trauma Plan
Pediatric Traumatic Splenectomy Vaccine Plan (Less than 15 Years of Age)
Pediatric VTE Prophylaxis Plan
PICU Trauma Plan
PICU Traumatic Brain Injury (TBI) Plan
Radiology Orders
In-Patient Radiology Pre-Procedure Requirements
Interventional Radiology Pre-Procedure Orders
IR Invasive Procedure Consult Form
Morphine Injection for Non-visualization of Gallbladder
Radiology/Endovascular Invasive OP Admitting Order
Respiratory Orders
Intubation Med Plan
Mechanical Ventilation Plan
Post Extubation Plan
Short Term Oxygen Therapy Plan
Respiratory Care Plan Protocol
Breast Pre-Op Orders
Concurrent Cisplatin Etoposide and Radiation
Concurrent Weekly Carboplatin Paclitaxel and radiation
Physician Order Sheet Breast Cancer
Physician Order Sheet Colorectal Cancer
Physician Order Sheet Lung Cancer
Standing Delegation Orders (SDO)
Adult Urinary Cath Removal SDO - Dr. A. Haynes
Anesthesia Pre-Op Screening SDO - Dr R. Johnston
Chemotherapy, Hypersenstivity and Flare Reaction SDO - Dr. Sanjay Awasthi
Endoscopy Anesthesia Pre-Op Screening SDO - Dr. R. Banister
General Newborn SDO - Dr. K. Robinson MD
OB/GYN Triage plan SDO - Dr. E. Yeomans MD
Pediatric All Better Care SDO Plan - Dr. Kasemri
Pediatric Urinary Cath Removal SDO - Dr. A. Haynes
Pt Topical SDO-Griswold
Rapid Response SDO - Dr. K. Nugent MD
Stroke Orders
Hemorrhagic Stroke Plan
Ischemic Stroke/TIA Plan
Stroke New Onset Plan
Thrombolytic Therapy Guidelines for Ischemic Stroke
Thrombolytic Therapy for ischemic Stroke Plan
Transfusion Services
BB Cord Blood Workup
BB Type and Screen
Urology Orders
General Urology Plan
Renal Lithiasis Plan
Transurethral Resection of the Prostate (TURP) Post-Op Plan
Vascular Orders
Open AAA Abdominal Post-Op Plan
Major Vascular Post-Op Plan
Thrombolytic Therapy for Peripheral Occlusion
Wound/Skin Care Orders
Standing Delegation Orders
Deep Tissue Injury OR Indeterminable (Mucosal) Wound Care SDO - Dr. J. Griswold MD
Denuded and or Fungal Yeast Infection Wound Care SDO - Dr. J. Griswold MD
Skin Tear Wound Care SDO - Dr. J. Griswold MD
Stage I Wound Care SDO - Dr. J. Griswold MD
Stage II Wound Care SDO - Dr. J. Griswold MD
Stage III or IV Wound Care SDO - Dr. J. Griswold MD
Unstagable with Slough Necrosis Wound Care SDO - Dr. J. Griswold MD
Protocol Reference Text
Adult Sepsis Anitbiotic Protocol
Adult Sliding Scale for Insulin Aspart
Arginine Clonidine Stimulation Test Guidelines
Alcohol Withdrawal Management Protocol
Alteplase or Other Thrombolytic Agent Reversal Guidelines
APRV Protocol
ARDSNet Protocol
BICU Smoke Inhalation HFOV Protocol
CDC Pneumococcal Vaccination Recommendations
CDU Abdominal Pain Inclusion Exclusion
CDU Asthma, COPD, CHF Inclusion Exclusion
CDU Chest Pain Inclusion Exclusion
CDU Toxicology Inclusion Exclusion
CDU Traumatic Injury Inclusion Exclusion Criteria
CV Surgery Insulin Protocol
DKA Insulin Infusion Protocol
EC Therapeutic Hypothermia Guidelines
EC Therapeutic Hypothermia Inclusion Exclusion Criteria
Ethanol Lock for Central IV Cath Guidelines
Electrolyte Replacement Guidelines
Factor Xa Inhibitors Reversal Guidelines
Hypoglycemia Guidelines
ICU Pain Aggitation Delirium
ICU Progressive Mobility Guidelines
Indwelling Urinay Catheter Guidelines
Insulin Drip Protocol
Intermittent-Continuous Telemetry
Intrapartum Insulin Infusion Guidelines
IV Direct Thrombin Inhibitors (DTI) Reversal Guidelines
Heparin Infusion Guidelines
LifeGift Continuous Insulin Infusion Titration Protocol
Low Molecular Weight Heparin Reversal Guidelines
Medically Indicated Breastfeeding Supplementation
MICU Ventilator Weaning Protocol
Neuromuscular Blocking Agent Guidelines
Newborn Discharge Requirements
Newborn Hypoglycemia Protocol
Ophthalmic Medication Administration Sequence
Oral Direct Thrombin Inhibitor Reversal Guidelines
Oxygen Therapy Protocol
Parenteral Nurtition Administration Guidelines
Parenteral Nutrition Formulation Form
Patient Status
Pediatric All Better Care Guidelines
Pediatric Alteplase Injection for CVL Guidelines
Pediatric Anticoagulant Nomogram Protocol
Pediatric DKA Two Bag IVF Alogrithm
Pediatric Insulin Dosing Orders for Patient Education
Pediatric Isolated Liver and Spleen Injury Guidelines
Pediatric Neuromuscular Blocking Agent Guidelines
Pediatric Tonsillectomy - Adenoidectomy Pain Protocol
Peripheral Nerve Stimulator Protocol
PICU Enteral Nutrition Clinical Practice Protocol Guidelines
PICU Induction and Maintenance Protocol
PICU Re-Warming Protocol
Pneumonia Recommended Antibiotic Therapy
Post Op Open Heart Orders for Respiratory Ventilator Care & Weaning
Pre-Operative Warming Orders
Protamine Dosing Guidelines
Radial Artery Compression Device Removal Guidelines
RCP Guidelines
SICU Adult HFOV Orders
Sliding Scale Insulin Regular Guidelines
Smoke Inhalation Injury Heparin Protocol
Snakebite Assessment Scale
TSICU/BICU Ventilator Weaning Protocol
Unfractionated Heparin Reversal Guidelines
Urinary Catheter Removal - SDO Adult Guidelines
Urinary Catheter Removal - SDO Pedi Guidelines
VAP Prevention Guidelines Pediatric
Warfarin Reversal Guidelines