For Our Physicians Preprinted Orders & Hospital Forms Preprinted Orders Core Measures Hospital Forms Patient References/Tools Translated Forms Unit Specific Orders & Forms Preprinted Orders Preprinted Orders and Hospital Forms Number Title Specialty 00040 Newborn Nursery Doctor's Treatment/Order Sheet Nursery 00145 Induction of Labor Obstetrics 00167 Pneumonia Orders - Adult Pulmonary 00194 Postpartum Orders Obstetrics 00255 Heart Transplant Telemetry Orders Adult Cardiac 00264 Heart Transplant Steroid Taper Orders Adult Heart Transplant 00269 Heart Transplant Pre Op Orders Adult Heart Transplant 00303 Renal with Pancreas or Solitary Pancreas Transplant- Adult Pre Op Orders Renal Transplant 00304 Renal with Pancreas or Solitary Pancreas Transplant - Adult Post Op Orders Renal Transplant 00312 - A Renal Transplant (only) Post Op Orders- Adult Cadaveric Donor or Living Donor with Less than 3 Antigen Match Renal Transplant 00312 - B Renal Transplant Post Op Orders, Adult Living Donor with 3-5 Antigen Match Renal Renal Transplant 00312 - C Renal Transplant Post Op Orders, Adult Living Donor with Identical HLA Match Renal Renal Transplant 00364 Heart Transplant Pre-Endomyocardial Biopsy Orders Heart Transplant 00419 Comfort Care : H&P Progress Notes and Disch. Sum.; Orders Non-Viable Live Birth Obstetrics 00495 Tocolysis for Preterm Labor Obstetrics 00583 Post-Anesthesia Treatment and Drug Orders (Phase I) Anesthesia 00670 High Dose Cyclophosphamide Orders Bone Marrow Transplant 00672 Stem Cell Infusion Bone Marrow Transplant 00674 Fever Order Sheet for BMT Patient Bone Marrow Transplant 00678 BMT Patient, Admission Orders (pp.1-2) Bone Marrow Transplant 00750 Epilepsy Monitoring Unit Admitting (Adult) Neuro 00826 Post-EP Study-Ablation Device Heart Cath 00831 Stroke Orders Acute, pgs. 1-2 Stroke 01025 Heart Transplant Post-Endomyocardial Biopsy Orders Heart Transplant 01028 Heart Cath, Post Orders Heart Cath 01084 GYN/Urogynecology (Post Op) Gyn 01118 TPN Order Form Adult TPN 01189 Percutaneous Coronary Intervention (Orders for) Heart Cath 01247 Percutaneous Cardiac Intervention Orders Post-PCI Heart Cath 01296 Pediatric, Daily Orders Parenteral Nutrition TPN & Pediatrics 01331 Caesarean Section for Admission Orders Obstetrics 01412 Status Epilepticus Protocol Neuro 01440 Chemotherapy Adult Order Form Oncology 01442 Pain Management Orders Acute Anesthesia 01471 Operative Pediatric Anesthesia Orders Anesthesia 01548 Outpatient Referral - Children's Center Order Pediatrics 01600 PUBS (More than 25 weeks) Obstetrics 01732 Heart Catherization Pre Op Orders Heart Cath 02113 Pediatric Urology Post-Op Orders - Dr. Shapiro Post Op 02134 Heparin Drip Protocol Maintenance Orders Protocols 02457 Anesthesia Pre-Operative Anesthesia 02503 Endoscopy Physician Record Surgery 02629 SCN (NICU) Doctor's Treatment Sheet SCN (Special Care Nursery) 02659 Therapeutic Apheresis Orders Oncology 02724 PUBS - Lab Orders Obstetrics 02766 ACL reconstruction without Patellar Tendon Bone Graft - Post Op Post Op 02767 Shoulder Replacement/Shoulder Repair Post OP Orders Post Op 02768 Hip Total Hip Replacement (Post Op) Post Op 02769 Knee Total Knee Replacement (Post Op) Post Op 02778 Cesarean Section Post-Op Orders Obstetrics 02809 HPC-A Human Hematopoietic Progenitor Cell Aphersis Collection Orders Bone Marrow Transplant 02884 Epilepsy Monitoring Unit Admit (Pediatric) Neuro 02927 Pediatric Emergency Procedure pp. 1-2 Hard Copy Only 05030 Pulmonary Admission Orders - Interactive PMA 05030 - 01 PMA/ICU - ICU Admission Orders PMA 05030 - 02 PMA/ICU Intensive Insulin Treatment Protocol PMA 05030 - 04 PMA/ICU Acute Respiratory Failure Orders PMA 05030 - 05 PMA/ICU ARDS Orders PMA 05030 - 07 PMA/ICU Acute Cardiac Orders PMA 05030 - 08 PMA/ICU Hypertension Control Orders IV PMA 05030 - 09 PMA/SVT Rapid Atrial Fib and Tachycardia, Related to Acute Coronary Syndrome PMA 05030 - 10 PMA/ICU GI Bleed -Anemia Orders PMA 05030 - 11 PMA/ICU Alchohol Withdrawal Orders PMA 06153 Magnesium Sulfate Obstetrics 09075 Fetal Death/ Stillborn Examination Obstetrics 09204 Angio Post-Angio Orders Diagnostic Imaging 09306 Hemodialysis, Outpatient Orders pp. 1-2 Hemodialysis 09332 Open Heart Surgery (Adult) Cardiac 09345 Restraint: Physician Order Hard Copy Only 09348 SNF Transfer Summary Hard Copy Only 09364 Cervical Discectomy Fusion (Post Op) Post Op 09365 Spinal Infusion +/- Instrumentation-SGH Post Op Orders pp. 1-2 Post Op 09366 Lumbar Discectomy/Laminectomy Post Op 09372 Preterm Labor/Preterm PROM Obstetrics 09414 Parental Nutrition Order Form Daily Neonatal/Infant PP. 1-2 TPN 09572 Induction of Labor Mid-Trimester Obstetrics 09697 SCN Vitamin/Mineral Protocol Orders for Infants Under 2kg SCN (Special Care Nursery) 09724 Pre-EP/Device Orders Heart Cath 09760 Chest Pain ACS/AMI Orders (Emergency) Chest Pain 09850 Emergency Procedures for Monitored and Non-Monitored Areas Hard Copy Only 09912 Heart Failure Admission Orders Cardiac 09939 Ventriculo - Peritoneal Shunt Placement/Revision Post Op 09940 Neuro Post Op Orders General Sutter Neuroscience Institute Post Op 09941 Craniotomy Sutter Neuroscience Institute Post Op pp. 1-2 Post Op 09942 Laminectomy for Spinal Cord Tumor Sutter Neuroscience Institute Post Op Post Op 09943 Transsphenoidal Sutter Neuroscience Institute Post Op Resection of Tumor/Cyst Post Op 09944 Sutter Neuroscience Institute Post Op Orders Multiple Suture Synostosis Pediatric Patients Post Op 09945 PO Laminectormy for Tethered Cord Post Op 10053 Adult Heart Transplant Immediate Post Operative Orders Heart Transplant 10066 Steroid and Antibiotic order for Preterm Labor/Preterm PROM Obstetrics 20001 SCN - Physician Admitting SCN (Special Care Nursery) 20018 D & C Orders, Pre Op Obstetrics 20020 Immunization Childhood Immunization 20021 tPA - Intravenous Thrombolytic Therapy for Acute Stroke Stroke 20037 Transfer - Acute Inpatient Summary Admission 20053 Comfort Care Orders Medical 20192 Spine Surgery (Post Op) Post Op 20196 Neurointerventional Post Procedure Orders Diagnostic Imaging 20279 Heart-Cath Post Op Orders - Pediatric Heart Cath 20429 Neuro Admission Orders Sutter Neuroscience Institute Neuro 20437 HCFW - Labor and Delivery Adm. Orders Obstetrics 20438 HCFW - Postpartum Orders Obstetrics 20439 HCFW - Post-Op C/Section Orders Obstetrics 20478 L & D OB Admission Orders Obstetrics 20495 Chemoembolization MIX instructions for Pharmacy Diagnostic Imaging 20496 Chemoembolization Pre Op DIRO Orders Diagnostic Imaging 20497 Uterine Artery Embolization - Post Procedure Orders Diagnostic Imaging 20498 Chemoembolization DIRO - Post Procedure Orders Diagnostic Imaging 20499 Uterine Artery Embolization Admission DIRO Diagnostic Imaging 20553 Lumbar Fusion Pre Op - Dr. L. Anderson Spine 20648 Outpatient Oncology (Pediatrics) Oncology & Pediatrics 20662 PICC Protocol Orders - Adult & Pediatric Protocols 20663 Chest Pain Rule Out Acute Coronary Syndrome Cardiac 20667 Ventilator Management Initial Physician Orders Ventilator 20718 Stroke Discharge Orders/Instructions and Prescription Stroke 20724 Gastric Bypass Surgery Post-Op Orders Bariatrics 20737 Anderson & Lemons, Pre Op Orders Spine 20758 Ventilator Discontinuation Ventilator 20759 Non Ambulance Order Form Hard Copy Only 20760 Ambulance Order Form Hard Copy Only 20763 Therapeutic Plasma Exchange - Apherisis Oncology 20792 Smoking Cessation Protocol Orders Protocols 20793 Pulmonary Infiltrates in ICU Adult Pulmonary 21034 Heart Failure Discharge Orders Cardiac 21044 Pediatric Heart Surgery Level 1 Immediate Post Op Orders pp. 1-3 Cardiac & Pediatrics 21045 Cardiovascular Intensive Care Unit - Adult Open Heart Surgery Immediate Postoperative Period Cardiac 21048 Adult Ketoacidosis & Hyperosmolar Non Ketotic Syndrome Diabetes 21052 Epilepsy Monitoring Unit - Post Op Phase II Craniotomy for Grid, Strip & Electrode Placement pp. 1-2 Neuro 21055 Craniotomy Post Op Dr's. Cobb, Robbins, Yen pp. 1-2 Neuro 21061 Cardiovascular Intensive Care Unit - Adult Open Heart Surgery Transfer Cardiac 21064 Acute Coronary Syndrome/Acute MI Admission Orders pp. 1-2 Cardiac 21065 Acute Coronary Syndrome Discharge Summary pp. 1-2 Cardiac 21069 Endoscopy Pre Procedure H&P Surgery 21075 Heated Intraperitoneal Chemotherapy Orders Sugarbaker Oncology 21078 Insulin Drip Non-Pregnant Adult (Physician Order) Diabetes 21092 Stroke Post Alteplase (t-PA) Acute Ischemic Orders pp. 1-2 Stroke 21133 Thoracotomy Post Op for Sacramento Cardiovascular Surgeons pp. 1-2 Pulmonary 21153 Renal and/or Pancreas Transplant Outpatient OKT3 Orders Muromonab-CD3 (Orthoclone OKT3) Adult Renal Transplant 21155 Renal / Pancreas Transplant Biopsy Admission Orders Adult Renal Transplant 21156 Renal Morning of Surgery Living Related/Unrelated Donor Renal Transplant Adult Pre Op Orders for Donor Renal Transplant 21157 Renal Morning of Surgery Living Related/Unrelated Donor Renal Transplant Adult Pre Op Orders for Recipient Renal Transplant 21158 Renal Outpatient Pre-Surgery Living Related/Unrelated Donor Renal Transplant Adult Outpatient Pre-Surg Orders for Donor Renal Transplant 21159 Renal Outpatient Pre-Surgery Living Related/Unrelated Donor Renal Transplant Adult Outpatient Pre-Surg Orders for Recipient Renal Transplant 21160 Renal Adult Transplant Protocol Orders for Living Donor Evaluation Renal Transplant 21180 HPC-A Continue or Stop Collection Orders for Human Hematopoietic Progenitor Cells Aphersis Collections Bone Marrow Transplant 21182 Renal Transplant (only)-Adult Pre Op Orders Renal Transplant 21186 Renal Transplant (Living Donor) Nephrectomy Post Op Renal Transplant 21187 Atrial Fibrillation Orders New Onset Post Op Dr. Arthur Cardiac 21208 Carotid Endarterectomy Sacramento Cardiovascular Surgeon's Perioperative Cardiac 21211 Wound and Skin Care Protocol Protocols 21218 OrthoPAT Orders Orthopedics 21241 Transcutaneous Pacemaker Orders Pediatric Cardiac & Pediatrics 21253 OB Anesthesia Orders Phase 1 Post Anesthesia 21258 Perioperative II Post Op Outpatient Surgery 21259 Surgery Admission Status Admission 21260 Gynecology/Urogynecology Patients Standard Admission Orders Gyn 21272 Cardiac Catheterization Laboratory Carotid Post Op Orders Heart Cath 21286 Chest Pain Evaluation Unit Cardiac 21301 Weaning Insulin Drip Pediatric Diabetes & Pediatrics 21302 Subcutaneous Insulin Pediatric Patient Diabetes & Pediatrics 21303 Insulin Drip Pediatric Diabetic Patient Diabetes & Pediatrics 21304 Diabetic Ketoacidosis Admission Orders Pediatric Diabetes & Pediatrics 21322 OB anesthesia Acute Pain Management Anesthesia 21324 Admission Orders- Adult Non -Surgical Admission 21327 WOCN Outpatient Orders Medical 21345 Pediatric CV Surgery PO Orders Level 2/Complex Pediatric Pediatrics 21346 PICU Post-op Heart Surgery Orders Level- 2 Pediatrics 21352 SCN Discharge Planning SCN (Special Care Nursery) 21358 EP Lab - Dr Kim's Post Procedure Orders Heart Cath 21359 Pediatric Continuous Renal Replacement Orders Pediatrics 21369 Total Joint Replacement Orthopedics 21390 Pneumococcal/Influenza Immunization Protocol (Please see Hospital Forms) Immunization 21395 Medication Reconciliation and Order Form Hard Copy Only 21405 Pre-Eclampsia Orders Obstetrics 21438 Hemodialysis Orders (adult) Dialysis 21487 Laparoscopic Gastric Band Surgery Post-Op Orders Bariatrics 21490 Bariatric Patient Discharge Orders and Prescription Bariatrics 21502 Carotid Enderarterectomy, Post Op Orders Cardiac 21515 Asthma - Pediatric Orders Specialty Pediatrics 21526 General Surgery (Colon) Post-Op Inpatient Orders Post Op 21529 Antenatal Testing Unit Orders Obstetrics 21531 Admission orders - Dr Morkoc Admission 21533 Percutaneous Carotid/Cerebral Angiography/Carotid Intervention Orders Pre Procedure 21534 Antepartum Orders Obstetrics 21553 Hepatic Chemoembolization with LC Beads (drug eluding beads) Diagnostic Imaging 21555 CBV Swog Version Bone Marrow Transplant 21556 Rituximab - BEAM Bone Marrow Transplant 21557 HD Melphalan Myeloma Bone Marrow Transplant 21558 HD Melphalan Modified - Myeloma Bone Marrow Transplant 21559 Flu-TBI Bone Marrow Transplant 21560 Flu-Cy Bone Marrow Transplant 21561 EC TBI Bone Marrow Transplant 21562 Cy3TBI Bone Marrow Transplant 21563 Cy2TBI Bone Marrow Transplant 21564 Germ Cell - CEC Bone Marrow Transplant 21565 CBV Standard Bone Marrow Transplant 21566 Busulfan - Etoposide Bone Marrow Transplant 21567 Busulfan - Fudarabine ATG (anti-thymocyte globulin) Bone Marrow Transplant 21568 Busulfan - Fludarabine Bone Marrow Transplant 21569 BuCy2 Bone Marrow Transplant 21570 Standard BEAM Bone Marrow Transplant 21571 HD Melphalan - Amyloidosis Bone Marrow Transplant 21573 Renal and/or Pancreas Transplant Physical Evaluation Renal Transplant 21579 Sepsis Bundle Worksheet and Orders (Adult) Medical 21584 Central Venous Catheter (Non-PICC) Post Insertion Protocol Orders Protocols 21587 Pediatric Diabetic New Diagnosis Discharge Planning Orders Diabetes & Pediatrics 21604 Weight Loss Surgery Preoperative Orders Bariatrics 21608 Nephrologists Results and Orders Nephrology 21610 Pre-Kidney and/or Pre-Pancreas Transplant Evalution Orders Renal Transplant 21612 VAD - Admission Orders Cardiac Cardiac 21613 VAD - Pre Op Orders Cardiac Cardiac 21614 Bilirubin Surveillance/Management Specialty Special Care Nursery Nursery 21617 Analgesia / Sedation Orders for Ventilated Patients Critical Care - Adult, Ventilator 21619 VAD Transfer Orders Specialty Cardiac Cardiac & Pediatrics 21620 Cytoxin /Ara C Peds Oncology Oncology & Pediatrics 21621 Urgent Admission Orders Inpatient Pediatric Oncology Oncology & Pediatrics 21622 Inpatient Chemotherapy Admission Orders Pediatric Oncology Oncology & Pediatrics 21625 Insulin Orders Adult Diabetes 21630 Anesthesia Peripheral Nerve Block Orders Anesthesia 21632 Subarachnoid Hemorrhage/Aneurysm Admission Orders Stroke 21635 Radical Prostatectomy - post op orders SMG Post Op 21636 High Dose methotrexate (MTX) Inpatietn Orders-Pediatrics Oncology & Pediatrics 21648 Adult Renal Replacement Orders (SLED) with Regional Citrate Anticoagulation Dialysis 21649 Renal Replacement (Adult) SLED with Heparin Anticoagulation Dialysis 21650 Adult Continuous Renal Replacement Orders Dialysis 21652 Bed Assignment Orders Specialty Admission Admission 21653 PO Uro Gynecology OP Procedures/Bowen & Hilger Post Op 21654 Remicade administration Orders Pediatrics Pediatrics 21658 Adult CRRT Orders with Heparin Anticoagulation Dialysis 21661 Diode Laser Therapy Protocol Orders - SCN SCN (Special Care Nursery) 21662 Eye Exam Protocol orders - SCN SCN (Special Care Nursery) 21667 Labor and Delivery Triage Orders Obstetrics Obstetrics 21668 L&D Triage Orders-General Obstetrics 21687 Pressure Ulcer Supplemental Orders Medical 21694 Adult Congenital Heart Surgery Immediate Post Op Orders Cardiac, Surgery 21704 Post Gastric Band Discharge Medication Order Bariatrics 21709 Peripheral Vascular Orders Post Op

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