Name
Item
Name of attending physician
text
Phone
Item
Phone number of attending physician
integer
Admitting Diagnosis
Item
Lower Gl Bleed Contributing Diagnoses
text
Activity
Item
Bed rest with bedside commode
boolean
Activity
Item
Bathroom privileges with assistance
boolean
Nursing
Item
ICU: per routine
boolean
Nursing
Item
Medical: every 1 hr until stable X4, then every 2 hrs until stable X4, then every 4 hrs
boolean
Nursing
Item
Notify MD for: BP < 90/60 or > 180/110, P < 60 or > 120, urine output < 30 cc/hr over 4 hrs, all H/H results
boolean
IV
Item
Bolus normal saline ____cc over ___
boolean
IV
Item
If Bolus normal saline, please specify amount
integer
IV
Item
If Bolus normal saline, please specify duration
integer
IV
Item
Dextrose 5% normal saline with 20 mEq KCl/L @____mL7hr total
boolean
IV
Item
If Dextrose 5% normal saline with 20 mEq KCl, please specify amount
integer
Lab
Item
Hemogram, comp met profile, PT/PTT/INR on admission
boolean
Lab
Item
HH every 6 hrs X24 hrs
boolean
Lab
Item
Type and screen for __ units PRBC
boolean
Lab
Item
If Type and screen, please specify units PRBC
integer
Other
Item
Have patient sign informed consent for blood transfusion
boolean
Signature
Item
Signature
text
Print Name
Item
Print Name
text
Date and Time
Item
Date and Time
datetime