Dat Physician’s Notes Order and Signature Time posted

e/ signature
Ti
me
12-6- Admitting orders
21
8:00 Please admit to ROC under my service
am

Secure consent for admission

VS q4h and record include FHT

May have light lunch then NPO after

Start IVF D5LR 1L x 8 hours once on NPO

LABS: CBC, Urinalysis

Meds: Cefuroxime 1.5 grams IV

( ) ANST as loading dose 1 hour prior to
OR
Fetal movement counting c/o patient

For preparation of CS 7pm tonight

Secure consent for procedure

Inform OR and NICU

Anesthesiologist: DR. Tiu
Pediatrician: Dr. Reyes
Abdominal prep pls

Bring patient to OR at 6:30 pm

Inform me of this admission c/o OB

resident on duty
Refer accordingly

Name: Leticia Ramos Age: 30 Room no: 305 Physician: Dr. M. Pascia
Date Physician’s
notes
12/06/21 Admitting orders
6:00 pm T/C Septic Please admit to isolation room under my service
Shock
Secondary to Monitor V/S q1
HAP
With DM type 2 I and O q shift
CBG q4
NPO
IVF D5NSS 1L+40 meqs kclx 200 cc/hr
Diagnostics:
● 12l ECG CBC, BUN, CREA, Na, K,
Mg, Ph, BUA, Ca, Alb, AST, ALT
● CXR Sputum GS/CS, U/A, Blood CS
x sites
Therapeutics:
● Piperacillin Tazobactam 2.25g IV q6
● Paracetamol 500 mg q4 PRN > or equal
to 37.8 degree Celsius
● D50 50 ½ vial for CBG < 70 mg/dl
● D50 50 1 vial for CBG < 50 mg/dl
O2 via FM at 7 LPM
WOF DOB, increase/decrease BP and HR
Inform MROD/ AP
Refer accordingly