Page 280 - 2023 SMOG Digital

FORMS

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 5 min Vital Signs [ ] Every 15 min Vital Signs [ ] Every 30 min [ ]
Continuous cardiac monitoring, document rhythm strips pre-flight and with any rhythm changes [ ]
ICP/CPP [ ] CVP [ ] GCS [ ] ETCO2 [ ] UO_____mL hourly
Activity: [ ] Bed rest
[ ] Spine precautions: C-Collar/C-Spine TLS Spine
Nursing: [ ] Wound VAC dressing to ______mm Hg 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 H2O Suction (circle: R L Both) [ ] Chest
tube 2 to: water seal (circle: R L Both) OR ______cm H2O Suction (circle: R L Both) [ ] Chest tube 3 to:
water seal (circle: R L Both) OR ______cm H2O Suction (circle: R L Both) [ ] Chest tube 4 to: water seal
(circle: R L Both) OR ______cm H2O Suction (circle: R L Both) [ ] Keep HOB elevated _______ degrees [
] Keep HOB flat
Respiratory: [ ] Keep O2Sat >______ %
Oxygen: [ ] Nasal Cannula at ______LPM [ ] Non-rebreather at _____ LPM
Ventilator Settings: Mode: [ ] SIMV [ ] AC [ ] CPAP [ ] BiPAP
Rate: ______breaths per minute I:E ratio:_________
Tidal Volume: ______ mL FiO2:______ % PEEP: ______cm H2O PIP: _____

280