Page 238 - 2026 SMOG

EXAMPLE: STANDING ORDER SHEET FOR
CRITICAL CARE PATIENT TRANSFERS
Patient Identification
Last, First, Middle Initial: ___________________________________________________________
SSN/Identification Number: _______________
Grade: _______________
DOB: _______________
Treatment Facility: ________________________________________________________________
Date: _______________
Sending Facility: __________________________________________________________________
Sending Physician: ________________________________________________________________
Receiving Facility: ________________________________________________________________
Diagnosis: _______________________________________________________________________
Condition: _______________________________________________________________________
Patient Category
Allergies: _____________________________________________________________________
Height: _______________
Weight (kg): _______________
Fluids: [ ] LR mL/hr [ ] NS mL/hr [ ] 3% Saline mL/hr [ ] D5W [ ] Other
[ ] PRBC [ ] FWB [ ] Plasma [ ] LTOWB
Monitoring: [ ] Vital Signs [ ] Every 5min Vital Signs [ ] Every 15min Vital Signs
[ ] Every 30min
[ ] Continuous cardiac monitoring, document rhythm strips preflight and with any rhythm
changes [ ] ICP/CPP [ ] CVP [ ] GCS [ ] EtCO [ ] UO mL hourly
2
Activity
[ ] Bed rest
[ ] Spine precautions: C-Collar/C-Spine TLS Spine
Nursing: [ ] Wound VAC dressing to _______ mmHg suction
[ ] NGT to low continuous suction OR [ ] Clamp NGT
[ ] OGT to low continuous suction OR [ ] Clamp OGT
[ ] Chest tube 1 to: water seal (circle: R L Both) OR cm H O Suction (circle: R L Both)
2
[ ] Chest tube 2 to: water seal (circle: R L Both) OR cm H O Suction (circle: R L Both)
2
[ ] Chest tube 3 to: water seal (circle: R L Both) OR cm H O Suction (circle: R L Both)
2
[ ] Chest tube 4 to: water seal (circle: R L Both) OR cm H O Suction (circle: R L Both)
2
[ ] Keep HOB elevated degrees _________ [ ] Keep HOB flat
(continues)

230 • REFERENCE