Republic of the Philippine

ISABELA STATE UNIVERSITY

Echague, Isabela

COLLEGE OF NURSING

DOCTOR’S ORDER

SURNAME: REID AGE: 2 HOSP. NO.: 21-001

GIVEN: AMBER MI: L SEX: FEMALE WARD: PEDIATRIC

PROGRESS ORDER ACTION TIME/SIG

NOTES
TPR every 4hrs. C-E March 24, 2021
7am- 7pm

CBC stat C-R-E

Routine urinalysis C–R-E

IVF: D5LRS 500cc to run for 12 hrs. C-A-E

Amoxicillin 300mg IVP ANST every 8 hrs. C–A-E

Vital Sign: Paracetamol 250mg 1 tsp every 4 hrs, PRN for C–A-E
PR- 85/min. fever
RR- 30/min
T-37. 9 C

Allerkid 1.5ml for 2 days C–A-E

Name: REID, AMBER L. Age/ Sex: 2 YEARS OLD/FEMALE Ward: PEDIATRIC Rm. No.:101

Nurses Action Legend:

C – Carried A – Administered R – Requested E – Endorsed
D – Discontinue
 Republic of the Philippine
ISABELA STATE UNIVERSITY
Echague, Isabela

COLLEGE OF NURSING

CONSENT FOR PROCEDURE/OPERATIONS/ANESTHESIA

TO WHOM IT MAY CONCERN

I, Margarette L. Reid, 32 years old, married/single/widowed hereby consent to the

performance upon Amber L. Reid who is my daughter, the procedure/operation/anesthesia
hereunto stated after these have been fully explained to me by the doctors and concerned
including the risk involved and their alternative procedure.

Explained by
Procedure/Operation/Anesthesia (Signature over printed Name
Of the Attending Physician)

I also consent for the proper disposal by the authorization of the Amber L. Reid or
whatever tissue maybe removed form myself/t/

I also consent to the taking of photographs in the course of this treatment of operation
for the purposes of advancing technical knowledge.

IN WITNESS WHEREOF, I hereunto set my hands this Wednesday March of 24,

2021 at Isabela State University Hospital Echague, Isabela.

___________________________
Patient’s signature or thumb mark
Of the person giving free consent

IN THE PRESENCE OF

MARGARETTE L. REID SAN FABIAN, ECHAGUE, ISABELA

Witness Address

ANALYN T. ANCHETA MALASIN, SAN MATEO, ISABELA

Interpreter Address