PLACE LABEL HERE
BLOOD and BLOOD PRODUCTS
ORDERS - Outpatient
 GMC Lawrenceville-Outpatient Treatment Center
678-312-4220
Fax To: 770-682-2209
 GMC Duluth- Procedural Nursing
678-312-6642
Fax To: 678-312-6645
Appointment Date and Time: _____________________  Gwinnett Medical Center Other: ___________
Patient Name: __________________________________ Date of Birth: ______________________________
Daytime Phone # _______________________________ Allergies: _________________________________
A note to all Physicians: Tests should only be ordered that are medically necessary for the diagnosis, symptoms and/or treatment. The
patient may be billed for tests that are not deemed necessary by payers. Please submit ALL (appropriate) clinical indications for ALL
tests(s) ordered.
CLINICAL INFORMATION / SIGNS / SYMPTOMS
NO RULE OUTS
_______________________________________________________
_______________________________________________________
_______________________________________________________
ICD-9 CODES
_____________
_____________
_____________
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
Blood and Blood Products
HGB___________
Date:_______
HCT___________
Date:_______
PLT___________
Date:_______
PT / PTT___________
Date:_______
1. Normal Saline IV at KVO for blood transfusion
2. Pre-meds:
 Tylenol (acetaminophen) 650 mg po x 1 dose
 Benadryl (diphenhydrAMINE) 25-50 mg x 1 dose  po IV
 Lasix (furosemide) ____ mg IV between units of blood
3. Type and crossmatch for _____ units of packed red blood cells (PRBCs)
 washed
 irradiated
4. Type and crossmatch for _____ units of platelets
 washed
 irradiated
5. Type and crossmatch for _____ units of fresh frozen plasma (FFP)
 washed
 irradiated
6. Transfuse when available
7. May go when transfusion completed
ADDITIONAL ORDERS:
______________________________________________________________________________________
______________________________________________________________________________________
The procedure will not be performed in the absence of the completed form including the appropriate diagnosis and/or ICD-9 code supporting
the ordered procedure. Ordering physicians are responsible for the accuracy of the information provided. Please fax form to the correct
department and have patient bring this form on the date of service.
______________
_____________
_________________________________
___________
Copy to pharmacy
*1-19626*
2
FORM 1-19626 REV. 05/2015
Page 1 of
COLECTOMY
POST-OP ORDERS
Date
FORM 3-15618
Time
REV. 07/2011
PLACE LABEL HERE
Physician Signature
PID Number
Send copy to pharmacy_________ (initials)
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