PHYSICIAN’S ORDER/PROGRESS NOTES

SURNAME:_______________________________________ M.I.:________ AGE:________ HOSPITAL NO.:_______________

GIVEN NAME:______________________________________________ SEX:________ WARD/ROOM NO.:______________

TIME POSTED
Date Progress Notes Doctor’s Order C A R E D AND
SIGNATURE

MAY 6, FOR EXLAP

2021 -PLEASE ADMIT TO ROOM OF CHOICE UNDER THE
SERVICE OF DR. REFUERZO
7AM BP – 110/70 -SECURE CONSENT FOR ADMISSION
RR – 21 -TPR Q SHIFT
PR – 97 -DIET: CLEAR LIQUID THEN NPO POST MIDNIGHT
TEMP – 36.4 DX:
WEIGHT – 65KG -CBC,CHEST XRAY, BLOOD CHEM, PROTHROMBIN
HEIGHT – 169CM TIME, 12 LEADS ECG, ABDOMINAL CT SCAN,
TX:
-START IV PNSS IL X 6HOURS
-FOR COLONOSCOPY TOMORROW FOLLOWED BY EX-
LAP AT 9AM
START:
-METRONIDAZOLE 500MG IV Q8 ANST
-NUBAIN 5MG AS NEEDED
-OMEPRAZOLE 40MG IV OD
-INFORM ANESTHESIOLOGIST DR. PLETE, INFORM OR
DEPARTMENT
-REFER TO DR. SABATEN FOR CP CLEARANCE AND
INFORM THE PROCEDURE
-REFER ACCORDINGLY

DR. QUILALA

10AM -SECURE 2 UNITS OF FWB, O POSITIVE

-1 UNIT TO BE TRANSFUSE AFTER PROPERLY
CROSSMATCHED
-PLEASE INSERT ANOTHER LINE FOR BT

DR. REFUERZO

THANK YOU FOR THIS REFERRAL

2PM - ECG IS NORMAL
-MAY PROCEED TO SAID SURGERY
-GIVE DULCOLAX 2 TABS AT 4PM
-CASTOR OIL 30CC AT 6PM, 8PM, 10PM THEN FLEET
ENEMA IN 5AM
-REFER AS NEEDED

DR. SABATEN

-NPO POST MIDNIGHT

5PM -ORAL AND BODY HYGEINE BEFORE OR
-KETOROLAC 30MG IV 1HR PTOR ANST
-REFER ACCORDINGLY

DR. PLETE

** Carried Administered Request Made Endorsed Discontinued

 PHYSICIAN’S ORDER/PROGRESS NOTES

SURNAME:_______________________________________ M.I.:________ AGE:________ HOSPITAL NO.:_______________

GIVEN NAME:______________________________________________ SEX:________ WARD/ROOM NO.:______________

TIME POSTED
Date Progress Notes Doctor’s Order C A R E D AND
SIGNATURE

May 7,
2021

2AM (+) FEVER -GIVE PARACETAMOL 300MG IV NOW

38.4
DR. QUILALA

MAY 7, -GIVE CEFOXITIN (MONOWEL) 2G IV NOW

2021
DR. REFUERZO
7AM

** Carried Administered Request Made Endorsed Discontinued