Raleigh General Hospital
Authorization is hereby given to dispense the generic equivalent unless otherwise indicated by the physician
Physician’s Order and Signature
Nausea/Vomiting, Adult
Date
Time
Medications:
http://www.uptodate.com/online/content/topic.do?topicKey=gi_dis/12029#H26
Zofran (Ondansetron) 4 mg IV every 8 hours as needed for nausea and vomiting.
Zofran (Ondansetron) 4mg PO every 8 hours as needed for nausea and vomiting.
Compazine (Prochlorperazine) 10mg IV every 6 hours as needed for nausea and vomiting.
Lab
http://www.uptodate.com/online/content/topic.do?topicKey_gi)dis/12029#H5
Chemistry
amylase level (serum)
STAT
Today
in the am
CMP (serum)
STAT
Today
in the am
Lipase level (serum)
STAT
Today
in the am
Beta hCG qualitative (serum)
STAT
Today
in the am
Beta hCG qualitative (urine)
STAT
Today
in the am
Hematology
CBC with differential
STAT
Today
in the am
Imaging
http://uptodate.com/online/content/topic.do?topicKey=gi_dis12029#H6
Computed Tomography
Abdominal/ Pelvis CT scan ________[contrast] STAT
Reason______________________
Abdomen CT scan_________ [contrast] STAT
Head CT scan_________[contrast] STAT
Contrast Study (non vascular)
Upper GI  STAT
 Today
In AM
Upper GI with small bowel follow-through study
Reason________________________________
Today
Today
in the am
in the am
Today
in the am
STAT
Today
Reason________________________
Reason_______________________
in the am
Magnetic Resonance
Brain MRI _______[contrast]
STAT
Today
in the am
Reason_________________________
Nuclear Medicine
Radionuclide gastric emptying scan
STAT
Today
in the am
Reason ________________________
Radionuclide hepatobiliary scan
STAT
Today
in the am
Reason ________________________
Today
in the am
Ultrasound
Abdomen ultrasound
STAT
Reason________________________
X-Ray
Routine [inspiration expiration] 2 view x-ray of the chest STAT
Today
in the am
Reason______________________________
Routine flat plate (KUB) and upright x-ray of the abdomen STAT
Today
in the am
Reason______________________________
Consults
Dietician
Reason______________________________________
Gastroenterology Reason______________________________________
Physician’s Signature ____________________________________________ Date:______________ Time: _______________
ALLERGIES & SENSITIVITIES
[
] NKA
PATIENT ID LABEL HERE
WEIGHT
HEIGHT
DIAGNOSIS
Verbal/Phone
Order Read
Back and
Verified with
Practitioner
YES
Raleigh General Hospital
Authorization is hereby given to dispense the generic equivalent unless otherwise indicated by the physician