Name

Age

Date of birth

Medical record

Status

If Other, please specify

Name of attending physician

Phone number of attending physician

Chest pain; R/O acute coronary syndrome Associated Diagnoses

Condition

Code Status

Allergies

Diet

If diet according to ADA, please specify amount of calories

If Other, please specify

Bed rest with bedside commode

Bathroom privileges

Up ad lib

Vital signs every 1 hr for 4 hrs then every 4 hrs

Notify MD for: T > 101.5, P > 120, BP < 90/60 or > 180/110, abnormal lab results

Weight on arrival

Continous cardiac monitoring; arrythmia orders

Stat ECG for significant chest pain

O2 at 2 L nasal cannula, notify MD if Pulse ox < 93%

Nitropaste 0.5 inch topically every 8 hrs

Enteric coated aspirin 325 mg PO now and every morning

NTG 1/150 SL prn CP, may repeat 15 min until pain free or max three tabs per episode

Morphine sulfate 5 mg slow IVP every 30 min prn severe chest pain

Tylenol 500mg 2 PO every 4 hrs prn headache/fever/pain

Ambien 10 mg PO at bedtime prn for insomnia

MOM 30 mL PO BID prn for constipation

Maalox 30 mL PO every 4 hrs prn for indigestion

IV lock; flush per routine

IV__@mL/hr

If IV__@mL/hr, please specify amount of mL/hr

Admission: CBC, basal metabolic profile, TSH, Troponin I every 8 hrs x2

Lipid profile in a.m.

CXR if not done

ECG every morning

Cardiolite stress test

Adenosine cardiolite stress test

Echocardiogramm - to be read by __

Echocardiogram-to be read by___?

Consult

Signature

Print Name

Date and Time