Name

Age

Date of Birth

Medical record

Status

Name of attending physician

Phone number of attending physician

ASA Overdose Associated Diagnoses

Condition

Code Status

Allergies

Diet

If diet according to ADA, please specify amount of calories

If Other, please specify

Bed rest with bathroom privileges

Vital signs every 4 hrs for 24 hrs then every 4 hrs if stable

Suicide precautions

Gastric lavage in ER with activated charcoal

Consider dialysis if serum salicylate greater than 70 mg/dl

Vitamin K 10 mg IM now

Guaiac all stools

Other

Dextrose 5% in 1/2 normal saline with 44mEq bicarbonate/L @ 300mL/hr (forced alkaline diuresis)

ABGs

Hemogram

Lytes

Glucose

Salicylate level, if not done in ER

Psych

Social services

MHMR

Signature

Print Name

Date and time