Discharge Summary Date: Time:
HN: Room:
Name:
Date of Birth Gender:
Age:
Physician:
Allergies: MD Code
Admission date ………….…..…. Time …………..…. Discharge date ……………....…Time …………..…. LOS ……..…..days AN. ……………………...............
Reason for Admission:
………………………………………………………………………………..…….……..……………………………………..…..……
Discharge Diagnosis
A. Principal Diagnosis : .........................................................…...…………………………………..……………….……………………………
B. Comorbidities : ..............……………………………………………………………………………………………………
....…………………………………………………………………………………………………………………………………
C. Complications : ......…………………………………………………………………………………………………………
....…………………………………………………………………………………………………………………………………
D. Other diagnosis :.....…………………………………………………………………………………………………………
...………………………………………………………………………………………….………………………………………
E. External Cause of Injury : …………………………………………………………………………………………………
....…………………………………………………………………………………………………………………………………
Procedure / Operation (s)
1. …………………………………………………………………………………………………………………………………
2. …………………………………………………………………………………………………………………………………
3. …………………………………………………………………………………………………………………………………
4. …………………………………………………………………………………………………………………………………
Significant Clinical and Investigational Findings :
……………………………………………………………………………………………………………………………..….………
……………………………………………………………………………………………………………………………..….………
……………………………………………………………………………………………………………………………..….………
……………………………………………………………………………………………………………………………..….………
……………………………………………………………………………………………………………………………..….………
Hospital Course, Medication (s) and Treatment :
……………………………………………………………………………………………………………………………………………………………..……….
……………………………………………………………………………………………………………………………………………………………..……….
……………………………………………………………………………………………………………………………………………………………..……….
……………………………………………………………………………………………………………………………………………………………..……….
……………………………………………………………………………………………………………………………………………………………..……….
……………………………………………………………………………………………………………………………………………………………..……….
Patient's condition upon discharge Type of discharge
By transfer
Recovered Dead (no autopsy) With approval Other (specify).............................
Improved Dead (autopsy) Against advice D ea th
Not improved By escape
Attending Physician’s Signature……………………………………MD Code.................Date ………………… Time …….…
FM-MSO-004-00
Short Stay & Day Surgery Date : ……………………………… Time : ………………………
HN : ……………………………….. Room : …………………….
Name : …………………………….. Gender : ………………...
Date of Birth : ………………...…… Age : ………………………
Physician : ………………………… MD code : ………………..
Allergies : …………………………………………………………..
Chief Complaint/Reasons for Admission: ............................................................................................................................. ...
Date of Surgery/Procedure: ...................................................................... N/A
History of Present Illness: ............................................................................................................................. ...............................
............................................................................................................................. ............................................................................
............................................................................................................................. ............................................................................
Past Medical History: Hypertension No Yes Heart disease No Yes DM No Yes
Hematological disease No Yes Kidney disease No Yes
Past reaction to GA No Yes Other........................................................................................
Past Surgical History: ............................................................................................................................. ......................................
Current Medications: None Yes
............................................................................................................................. ............................................................................
Allergy: Drug No Yes............................. Latex No Yes...........................................
Social History: Alcohol No Yes Tobacco No Yes Illicit Drug No Yes
Pertinent Review of System: (Check if present) : Active cough Fever Shortness of Breath
Chest pain Other ...............................................................
Physical Examination: Pulse .................... /min R .................... /min BP...................... mmHg
Vital Signs: Temp .................... oC
Mental status: Normal Abnormal ................................................................................................................... ........
Head and EENT: Normal Abnormal ................................................................................................................... ........
Neck: Normal Abnormal ................................................................................................................... ........
Chest: Normal Abnormal ................................................................................................................... ........
Heart: Normal Abnormal ................................................................................................................... ........
Abdomen: Normal Abnormal ................................................................................................................... ........
Extremities: Normal Abnormal ................................................................................................................... ........
Genitourinary: Normal Abnormal ................................................................................................................... ........
Neurological: Normal Abnormal ................................................................................................................... ........
Skin: Normal Abnormal ................................................................................................................... ........
Diagnosis/Pre-op Diagnosis: ...........................................................................................................................................................
Surgery/Procedures: ......................................................................................................... ..............................................................
Plan/Treatment/Hospital Course: ............................................................................................. .......................................................
............................................................................................................................. ............................................................................
Physician's Signature.......................................................... MD Code.................... Date........../.. .........../........... Time...................
Discharge Status: Stable/improved Full Admission Room............... Transfer......................................... AMA
Discharge Date............................................................................................................... .................................................................
Physician's Signature.......................................................... MD Code.................... Date........../.. .........../........... Time...................
FM-ERD-007-00
Admission Note Date: Time:
History & Physical Examination HN: Room:
Name:
Date of Birth: Gender:
Physician: Age:
Allergies: MD Code
Chief Complaint : ............................................................................................................................. ........................
............................................................................................................................. .......................................................
History of Present illness :
.....................................................................................................................................................................................
............................................................................................................................. ........................................................
............................................................................................................................. .......................................................
............................................................................................................................. .......................................................
............................................................................................................................. ........................................................
............................................................................................................................. ........................................................
............................................................................................................................. ........................................................
............................................................................................................................. ........................................................
............................................................................................................................. ........................................................
............................................................................................................................. ........................................................
............................................................................................................................. ........................................................
............................................................................................................................. ........................................................
............................................................................................................................. .......................................................
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............................................................................................................................. ........................................................
............................................................................................................................. ........................................................
............................................................................................................................. ........................................................
............................................................................................................................. ........................................................
............................................................................................................................. ........................................................
Allergy : No known allergy
Yes, as listed above
Additional allergy ............................................................................
Past Medical History : Current Medications :
Childhood / Adult Illness............................................... None
...................................................................................... Per medication reconciliation form
......................................................................................
...................................................................................... ...............................................................................................
...................................................................................... ...............................................................................................
...................................................................................... ...............................................................................................
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...................................................................................... ...............................................................................................
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Page 1/3 FM-MSO-007-00
Admission Note Date: Time:
History & Physical Examination HN: Room:
Name: Gender:
Date of Birth: Age:
Physician:
MD Code
Allergies:
Past Medical History (Continued) :
Menstrual History : N/A LMP ................................................. Menopause
Previous Surgery : .......................................................................................................... ..........................................
............................................................................................................................. .....................................................
Previous Hospitalization : .........................................................................................................................................
............................................................................................................................. ..................................................
Social History : Unable to obtain information Student
Occupation : ..................................................................
Tobacco No Yes ......... pack year Alcohol No Yes........... Illicit drug No Yes............
Significant Family History : No Yes Unable to obtain information
If yes, please specify below :
Hypertension :............................................................... DM :...................................................................
Heart disease :.............................................................. Kidney disorder :........................ .......................
Hematological disease :............................................... Cancer :....................................... ......................
Other :………………...…………………………………………………………….................................................
Review of Systems : (N = Negative, P= Positive) N/A or unable to obtain information
Systems NP Comment
Constitutional
Eyes
ENT / Mouth
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin / Breasts
Neurological
Psychiatric
Endocrine
Hematological / Lymphatic
Allergic / Immunologic
Page 2/3 FM-MSO-007-00
Admission Note Date: Time:
History & Physical Examination HN: Room:
Name: Gender:
Date Of Birth: Age:
Physician: MD Code
Allergies:
T oc Pulse / min R / min BP mmHg BW Kg Ht cm
Vital Signs
Systems : Normal Abnormal Remarks
1. General
2. Skin
3. Head
4. Eyes
5. ENT
5.1 Ears
5.2 Nose
5.3 Mouth / Throat
6. Neck
7. Chest / Lungs
8. Breasts
9. Back
10. Heart
11. Blood Vessels
12. Abdomen
13. Lymphatics
14. Musculoskeletal
15. Extremities
16. Neurological
17. Rectal
18. Genitalia
Impression :
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
Plan : ............................................................................................................................. ............................................
............................................................................................................................. ........................................................
…… ……… ……… ……… ……… ……… ……… ……… ……… ……… ……… ……… ……… ……… ……… ……… ……… .
I have discussed diagnosis and plan with patient / family ; who agreed and voiced understanding.
Please see Electronic Medical Record
Physician’s Signature ............................................. MD Code.....................Date .....................Time ..............
Page 3/3 FM-MSO-007-00
Consultation Request Date: Time:
HN: Room:
Name: Gender:
Date of Birth : Age:
Physician: MD Code
Allergies:
To .................................................................................. From .........................................................................
Reason for consultation
Physician's Signature.............................................. MD Code ….............................
Report of consultation
Physician's Signature........................................... MD Code ................................
Date ............................................ Time ............................................
FM-MSO-008-00
Progress Note Date: Time:
HN: Room:
Name: Gender:
Age:
Date of Birth: MD Code
Physician:
Allergies: FM-MSO-006-00
Date Progress Note
Time
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Patient Care Team (Physician) Date: ………………………………….…..Time:……………….......….…
HN.:……………………………….….……Room:…………………..........
Name:……………………..…………...…Gender :……….. ……..……….
Date of Birth:………………………..……Age:………….…………..……
Physician:…………………..……...……..MD Code:………..…..…....…
Allergies:………………………………….……………………….....……..
Date Time Physician Name Code Signature Procedure/Care Provider Role
FM-IPD-034-02
Multidisciplinary Care Plan Date: Time:
HN: Room:
Name:
Date of Birth: Gender:
Physician: Age:
MD Code
Allergies:
Diagnosis/Problem list Date Goal/Plan of Care Signature/ Target Date
Discipline Code Date Goal Met
Discipline Codes: MD = Physician
NST = Nutrition Support Team RN = Registered Nurse
RPh = Registered Pharmacist PT = Physical Therapist
OT = Occupational Therapist
FM-IPD-008-00
Physician’s Order Date: Time:
HN:
Name: Room:
Gender:
Date of Birth: Age:
Physician:
Allergies: MD Code
Date ORDER FOR One DAY Date ORDER FOR CONTINUATION
Time Time
New Allergies History :......................................................... Informer signature ......................………....Employee ID ..................
FM-MSO-002-00
Physician’s Order For DM Date: Time:
HN: Room:
Name: Gender:
Age:
Date of Birth: MD Code
Physician:
Allergies:
Allergy □ Not known allergy □ Side effect to.…..……...............................................................
Date □ Allergy to ……………………………………………………………………………………………...
Time
Date
ORDER FOR 1 DAY ONLY Time ORDER FOR CONTINUATION
Order For DM Foot Diet □NPO
□Diabetic Arabic Diet □Low salt diet □Low fat diet
- Admit to ICU Ward …………...
Regular Soft Liquid
- Condition Stable Guarded Critical
□เพ่มิ ไขข่ าวมอื ้ ละ..........ฟอง
□DM Package (ส่งทุกราย) □Record vital sign and intake / output every ……..hour (s)
□Access vascular by Doppler ultrasound every day (s)
(CBC, FBS, HbA1C, SGOT, SGPT, BUN, Cr, Lipid □Observe สีนวิ ้ เท้า .........................every……..hour (s)
□DTX premeal and hs Keep blood glucose ……...mg/dl
Profile, Electrolyte, Anti HIV, Urinalysis, Urine micro □Measure body weight every week
□Fall precaution
albumin, EKG, CXR, ABI, Eye Exam, Dental Exam)
Position :
□hs-CRP □ESR □CPK
□ยกขาข้าง………….สงู □ห้ามส้นเทา้ แตะพืน้
□PTT □PT-INR □Ferritin □Bed Sore precaution with alphabed
□พลกิ ตะแคงตวั ทกุ 2 ชม.
□Serum Iron □TIBC □LFT
Warmer :
□Anti HCV □Anti HBs □HBsAg
□On Beir Hugger Temp ……..…… C0
□Magnesium □Phosphorous □Calcium
HBOT :
□FT3 □FT4 □TSH
□HBOT………….….ATA for …...…..min OD / BID
□25-OH Vitamin D □Other ……………………...…….. □For ……………… session , after complete please notify
□Transcutaneous oxygen measurement at both feet Observation :
□Hemoculture from …………….………..for specimens □Observe bleeding
□Observe Capillary refill and color q ………. hrs.
□Pus □Tissue from………………………….…….. □Observe pulse by Doppler ultrasound q ………..
□On vacuum dressing / suction wall
For Gram Stain Culture
Pressure ………………….mmHg.
□G/M for LPRC…….Unit. FFP……Unit.
□Check vacuum dressing q 4 hrs.
SDP……Unit. LPPC…..Unit.
□Imaging: X-ray foot AP and Oblique
Left Right
□MRA both legs with gad
□CTA both legs with contrast
□Echocardiogram
Page 1/2 FM-DWC-004-00
Standing Order for Date ……………………………………..Time ……………………….
Post Operative (TDWC) HN. ………………………………………Room: ………………........
Name: ………………………………...…Gender………..…………..
Date of Birth: …………………………….Age: ………….……..……
Physician: ………………………………..MD Code…………………
Allergies: ………………………………..……………………………..
Allergy □ Not known allergy □ Side effect to.…..……...................................................................................................................
□ Allergy to ……………………………………………………………………..................................…………………….................…...
Date Order for One day Only Date Order for Continuation Date(OFF)
Hour Hour Hour
Post-OP order for ………………………………..……………… Diet
By Dr. Borripatara
□ NPO □ จบิ นา้ ได้
- Admit to □ ICU □ Ward ……………………....
- Routine Post Operative Care □ Diabetic Arabic Diet □ Low salt
- Post operative notify แพทย์เจ้าของไข้
□ Culture : Pus/ tissue □ Soft diet □ regular diet
from ………………………………….….……………..………
□ Pathology: □ Record V/S ทกุ 15 นาที 4 ครัง้ , ทกุ 30 นาที 2 ครัง้ , ทกุ 1 ชวั่ โมง 1 ครัง้
from ………………………………….….………………..……
□ NPO จากนนั้ ทกุ 4 ชว่ั โมง
□ ต่นื ดกี ินได้
□ IV Fluid ……………………………….………………….…… □ Record I/O every 4 hrs.
Initial Lab for DM
□ Post Operative Laboratory investigation □ Record drain every 4 hrs.
………………………………………………….………………….
□ Plasil 10 mg. IV prn q………… for nausea or vomiting □ Fall precaution
Pain control
□ Fentanyl …….…..mcg IV ……………………………….…… Observation:
□ Morphine ………..mg IV …………………………………......
□ Tramol ………..… mg IV ……………………………….……. □ Observe bleeding
□ Dynastat ………..mg IV …………………………..…………
□ Other ………………………………………….………..……… □ Observe Cap refill and color q …….. hr.
□ Observe Vascular status
by doppler ultrasound q ………………..hr.
□ On vacuum dressing continuous pressure ……..…mmHg,
and check vacuum dressing q 4 hr.
□ Off vacuum dressing
□ On suction wall pressure …………mmHg.
and check q 4 hr.
Positions:
□ ยกขาข้าง ............ สงู
□ ห้ามส้นเท้าแตะพืน้
□ พลกิ ตะแคงตวั ทกุ 2 ชม.
Warmer :
□ On Bier Hugger Temp……… Cº
Medication:
□ Continue Current medication
□ Tylenol 500 mg 1 tab oral PRN for pain or fever q 6 hr.
□ Tramol 50 mg 1 cap oral tid PC
□ Ultracet 1 tab oral tid pc
□ Fentanyl patch 25 mcg แปะ เปลยี่ นทกุ 72 hr.
Physician’s Signature…...…………………..…….…………….. Physician’s Signature…...………………………………..……………..
(................................................................) (........................................................................)
Medical License No. ……….…………………...………………. Medical License No. ……….……………….………………………..….
FM-DWC-010-00
Physician’s Order : Admission Date: Time:
HN: Room:
Name:
Date of Birth: Gender:
Physician: Age:
Allergies: MD Code
Date ORDER FOR ONE DAY ONLY Date ORDER FOR CONTINUATION
Time Time
Admission: Regular Short stay
Planned Admission Date ..................................... Admit to: (Location)
Passed Flu Screening
Regular ward and on telemetry
Signature……………………Position...…………….
Critical care unit Pediatric special care
Attending Physician: ........................................…
MD Code: ..........................................................…
Admitting Diagnosis/Reason for admission: ….…
........................................................................
........................................................................
Patient's Condition : Stable Guarded
Critical
Activity: Bed rest No restriction
Diet: .................................................................…
Vital signs every ..............................................…
Neurological signs every..............................……...
Medicine
Analgesic
..................................................................
Laxative
..................................................................
Sleeping pills
..................................................................
Physician's Signature ...................................……. Physician's Signature ....................................…….
MD Code ...............................................................……... MD Code ...............................................................……...
New Allergies History :.......................... Physician : RN's informed signature ..............................Employee ID …….......…
FM – MSO – 003 - 00
Medication Reconciliation Date: Time:
HN: Room:
Name:
Date of Birht Gender:
Physician: Age:
Allergies: MD Code
Information Source (at least 2 sources)
If able to obtain medication history from only 1 source with Reason:………………………..………………….…….……
1. From HIS (Ex. Home Medication List) 2. Patient or Caregiver 3. Patient 's own medication
4. Discharge medication schedule 5. Patient’s own medication list Other……………………….……..
Transferred from other hospital, please see the information in transferred document.
Unable to obtain medication history with in 24 hours with Reason:.........................................................................
...................................................................................................................................................................................................
Disposition of Patient's Medications upon Admission
Not brought to hospital Locked up Brought home by…………………………………………....….....….
To be reconciled by:......................................................... (RPH’s Signature/ID) Date........./…....../.......... Time..................
List all of the patient’s medications nutritionals, herbal supplement used prior to this visit or admission
Medication Name Last Taken Medication
(Write Legibly) ordered
No Dose Route Frequency Comment
Date Time Yes No FM-IPD-003-00
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Remark: Patient instructed not to take own medication
OR Schedule Order Date: Time:
HN: Room:
Name: Gender:
Age:
Date of Birth: MD Code
Physician:
Allergies:
Surgery / Procedure…………………………………………..Scheduled Date…………………….Time………………...hr.
Diagnosis……………………………………….………………...Estimate Surgical Time……………...……………………hr.
Surgeon / Doctor……………………………………………….Assistant……………………...…..……………………..………
Anesthesiologist (If requested)………………………………………………………………………………………………..…….
Daily Order Date/ Investigation
Time(hr.)
- NPO : Date……../ ……../…….. Time……….hr. PART A: Mandatory for general or regional anesthesia
- Pre-op consultation for Medical clearance Medical Clearance is optional for local anesthesia
and emergency patient
O NO O Yes By Dr………………. 1. Patient Age ≤ 15 years old —> Ped. Consult
- Post Operation plan transfer to higher level of care - CBC
2. Patient Age > 15 - 40 years old
O Intermediate Care Unit (specify) - CBC
O Critical Care Unit (Specify) 3. Patient Age > 40 - 60 years old —> Optional Med.
◻ Special Equipment : (please specify) Consult
1. ……………………………………………………….. - Blood sugar (Fasting / Non-fasting)
2. ……………………………………………………….. - CBC
3. ……………………………………………………….. - Creatinine
- EKG
Physician's Signature …………………………….…… - CXR
Medical License number ………………………….…. - Urine Analysis
4. Patient Age > 60 years old, or Patient at any age
with active underlying disease —> Mandatory Med.
Consult
(eg. DM, HTN, CAD, Asthma, Functional Thyroid
Disease, COPD, Chronic renal failure, Chronic liver
disease, Coagulopathe, Heavy tobacco use)
- Blood sugar (Fasting / Non-fasting)
- CBC
- Creatinine
- EKG
- CXR
- Urine Analysis
5. Additional laboratory tests:
Anti HIV
6. Other (if any)………………………………………………
PART B:
Frozen section Time………………… hr.
Pathologist (If requested) Dr……………………………….
OPD Clinic / IPD Nurse……………………………… Received schedule order by (OR Nurse)……………………………
Date………...………..Time……………..hr. Date………...………..Time……………..hr.
FM-ORD-007-00
Physician's Order Pre Angiogram Date ……………………………………..Time ……………………….
HN. ………………………………………Room: ………………........
Name: ………………………………...…Gender………..…………..
Date of Birth: …………………………….Age: ………….……..……
Physician: ………………………………..MD Code…………………
Allergies: ………………………………..……………………………..
Diagnosis……………………..…………………………………………………………………………………………..…………………….…………………………
Allergy Not known allergy Side effect to………..........................................................................................................................…......………
Allergy to …………….......................................................................................................................................................................................…………
Weight……………………kg. นำ้ หนกั ลด มี ไมม่ ี (3 kg. ใน 1 เดอื น) BMI 18.5 or 35 มี ไมม่ ี
Date/ คำส่งั ใช้ได้วนั เดียว Date/ คำส่งั ใช้ได้ตลอดไป
Time (ORDER FOR ONE DAY ONLY) Time (ORDER FOR CONTINUATION)
Admit for ………………………………………….…………….…………
[ ] Inform consult a give education to patients before Angiogram Activity ;
[ ] Notify Cardiologist Confirm Angiogram time………….น. [ ] Bed rest [ ] AS tolerate [ ] Other.........................
[ ] NPO 4-6 hr. before procedure at ………….น. Diet :
[ ] 0.9 % NSS 1000 ml. KVO [ ] NPO ยกเว้นยำและนำ้ (ไม่รวมยำเบำหวำน)
[ ] On NSS lock [ ] Clear liquid diet
[ ] Lab : CBC , BUN , Cr , Electrolyte , Anti HIV , Trop-T , PTT, PT, FBG [ ] Diabetic diet (clear, soft, regular)
INR if ผ้ปู ่ วยกิน Warfarin
[ ] Notify Doctor if Lab > 1 month, and K ≥5 mEq/L [ ] 2 gm Na/day
Cr ≥ 2 mg/dl , INR ≥ 1.3 [ ] Low saturated fat & low cholesterol
[ ] EKG 12 leads (with 1 month)
[ ] CXR (with 1 month) (clear, soft, regular)
[ ] Other…………………………………….……….….……
[ ] Diazepam (2) 1 tab Oral pc ถ้ำ conscious ปกติ
[ ] ASA ( 81 mg.)…... tab Oral (ยกเว้น GI bleed) เคีย้ ว
[ ] ASA (300 mg.) ..... tab Oral (ยกเว้น GI bleed) เคีย้ ว
[ ] Plavix (75 mg.) ….. tab Oral stat
(ยกเว้นผ้ปู ่ วยที่มำทำ Pre-op หรือ Rt. Heart cath , GI bleed)
[ ] ให้ 10% E.KCL ..... ml. Oral stat ยกเว้น ESRD
(ถ้ำ K = 3.5-3.9 ให้ 10% E.KCL 10 ml ,K ≤ 3.5 mEq/L ให้ 10% E.KCL 30 ml)
[ ] Cr ≥1.5mg/dl or GFR <20 ให้ Flumucil (600 mg) ทกุ 12 hr. x 2 dose
[ ] แพ้อำหำรทะเล ให้ Dexamethasone inj (4 mg) + CPM inj (10 mg) IV stat before
Procedure
[ ] ประวตั ิ GI bleed ให้ Omeprazole inj (40 mg) IV stat
[ ] Call code STEMI
[ ] Morphine………….………..mg iv stat for pain
[ ] Isordil 5 mg 1 tab or SL for chest Pain
[ ] On Injection plug / IVF Lt. Hand (Separate Inotropic drug to other IV site)
[ ] Shave both groin and Mark pedal pulse
[ ] Shave and Clean perineum
[ ] Shave and Clean Axillary
[ ] Void before moving to Angiogram
[ ] Notify Intervention Radiology If patients take anti coagulant medicines
[ ] Ensure for Questionnaire of Assessment and History : Contrast Media done
[ ] Obtain consent for surgery or procedure
[ ] Obtain consent for Pre – moderate to deep sedation and Pre – anesthesia
Informed consent
[ ] Other………………………………………….……………………………...…..
Physician’s Signature…………………………………..………………..………… Physician’s Signature……………………………..…………
MD Code………………………………Date……….…………Time……….…….. MD Code……………………Date……………Time………..
FM-DSA-002-00
Physician's Order Post Angiogram Date ……………………………………..Time ……………………….
HN. ………………………………………Room: ………………........
Name: ………………………………...…Gender………..…………..
Date of Birth: …………………………….Age: ………….……..……
Physician: ………………………………..MD Code…………………
Allergies: ………………………………..……………………………..
Diagnosis……………………..…………………………………………………………………………………………..…………………….…………………………
Allergy Not known allergy Side effect to………..........................................................................................................................…......………
Allergy to …………….......................................................................................................................................................................................…………
Weight……………………kg. นำ้ หนกั ลด มี ไมม่ ี (3 kg. ใน 1 เดอื น) BMI 18.5 or 35 มี ไม่มี
Date/ คำส่งั ใช้ได้วนั เดียว Date/ คำส่งั ใช้ได้ตลอดไป
Time (ORDER FOR ONE DAY ONLY) Time (ORDER FOR CONTINUATION)
[ ] After the procedure Admit patient to CCU/ICU Activity ; [ ] Bed rest [ ] AS tolerate [ ] Other.......................
[ ] After the procedure Admit patient to Ward Diet : [ ] NPO ยกเว้นยำและนำ้ (ไมร่ วมยำเบำหวำน)
[ ] Echocargiogram…………………….…….........................................…….. [ ] Clear liquid diet
[ ] Remove introducer sheath at……….……น. [ ] Diabetic diet (clear, soft, regular)
[ ] Apply sandbag 1 kg to puncture site for 4 hrs. after remove sheath
off sandbag at …………….. น. [ ] 2 gm Na/day
[ ] Absolute bed rest with head elevate ( not over than 30 degree ) [ ] Low saturated fat & low cholesterol (clear, soft, regular)
[ ] Other…………………………………….…………..….….……
[ ] Stretch Rt. / Lt. Leg , Rt ./ Lt. Hand for 6 hr. [ ] Monitor I/O 8 hrs.
[ ] หลงั off Sheath ลกุ นงั่ ได้ เวลำ...............................น. [ ] Restrict oral find < 1 L/day
[ ] กรณี radial sheath หลงั off sheath radial 4 hr. เร่ิม release pressure [ ] Oxygen as required
ครัง้ ละ 2 ml. ทกุ 15 นำที x 4 ครัง้ ถ้ำไมม่ ี bleeding ให้ off ได้ [ ] Education for routine post CAG or PCI care
[ ] V/S q 15 mins x 4 then q 30 mins x 2 then q 1 hr. unit stable Medication :
(Notify if abnormal) [ ] ASA ( 81 , 300 , 325 ) 1, 2 tab X 1 ๏ pc
[ ] Chest pain assessment [ ] Clopidogrel (75) 1 tab X 1 ๏ pc
[ ] Check distal pulsation q 15 min x 4 then q 30 min x 2 then q 1 hr. [ ] Prasugrel (10) , Ticagrelor 1 tab X 1, 2 ๏ pc
until stable [ ] Omeprazole (20) 1 tab X 1, 2 ๏ ac
[ ] กรณี radial sheath ให้ Check O2 sat ปลำยนวิ ้ ทงั้ สองข้ำง [ ] Ranitidine (150) 1 tab X 1, 2 ๏ pc
keep O2 sat ≥ 95% [ ] Digoxin (0.25) 1/4 , 1/2 , 1 tab X 1 ๏ pc
[ ] Observe bleeding and hematoma at puncture site [ ] Isordil Dinitrate (10) 1 tab X 2, 3 ๏ ac
[ ] Lab as order [ ] Isordil Mononitrate (Ismo) (20) 1 tab X 2 ๏ ac
[ ] EKG 12 Lead Post PCI [ ] Amlodipine (10) 1/2 , 1 tab X 1 ๏ pc
[ ] Paracetamol (500 mg) 1 tab Oral prn for pain q 4 hr. [ ] Atenolol ( 50 , 100 ) 1/2 , 1 tab X 1 ๏ pc
[ ] Other…………………………………………………………………............. [ ] Carvedilol (12.5) 1/4 , 1/2 , 1 tab X 1 , 2 ๏ pc
…………………………………………………………………………………….. [ ] Metopolol (100) 1/2 , 1 tab X 1 ๏ pc
[ ] Enalapril ( 5 , 20 ) 1 tab X 1 , 2 ๏ pc
[ ] Losartan (50) 1 tab X 1 ๏ pc
[ ] Simvastatin ( 10 , 20 , …. ) 1 tab ๏ hs
[ ] Aldactone (25) 1 tab X 1 , 2 (ช/ท) ๏ pc
[ ] Lasix (40) 1 tab X 1 ๏ pc
[ ] Ativan ( 0.5, 1 ) 1 tab ๏ hs ถ้ำนอนไมห่ ลบั
[ ] Senokot 2 tab ๏ hs ถ้ำท้องผกู
[ ] Clexane (0.4 ml. , 0.6 ml.) SC. q 12 hr , q 24 hr
[ ] Other…………………………………………………………….
[ ] Consult Rehabilitation / Nutrition / Pharmacologist
before D/C
Physician’s Signature……………………………….…………………..………… Physician’s Signature……………………………..…………
MD Code………………………………Date…………………Time…………….. MD Code……………………Date……………Time………..
FM-DSA-003-00
Pre – Permanent Date: ………………………………….…..Time:………………....….…
Pacemaker Order HN.:……………………………….….……Room:………………..........
Name:……………………..…………...…Gender:………..……..…….
Date of Birth:………………………..……Age:………….………..……
Physician:…………………..……...……..MD Code:………..…..….…
Allergies:………………………………….………………………..……..
Date / Time Daily Order Continuous Order
Procedure : Date………………………......…Time…………...........…….. FM-DSA017-00
1. Special Equipment Requested
DDD (dual chamber)
VVI (single chamber)
DDDR (dual chamber rate responsive)
VVIR (single chamber rate responsive)
AICD (automatic implantable cardioverter defibrillator)
CRTD (cardio resynchronization therapy - defibrillator)
CRT-P (cardio resynchronization therapy - pacing)
Other………………………………………..................………………
2. EKG (if not done within 3-7 days)
3. Chest X-Ray (if not done within 3 months)
4. Lab;
CBC Creatinine
Prothrombin time (PT) BUN
Partial Thromboplastin time (PTT) Electrolyte
Other…………………………………...................………………..…
5. Shave and Prep………………………….................……………....……
6. NPO…………….hr. before Procedure
7. Notify Physician………………….………........................………………
8.Consult Anesthesiologist………………..................………...………….
9. Alert Technical Sales Representative;
Medtronic Boston Scientific
Other……………………..………...................…........……...………
10. Alert Incharge of Cath Lab……….................………….……………..
11. Alertm Physician if Lab Result is abnormal
12. Check vital sign and have patient void before going to
the Cath Lab
13. Send the patient, together with full medical record to Cath Lab
at……...…………...……………..................................…………………….
14. IV fluid………………………........…...……Start at……..........……….
15. Pre-Medication;
Physician’s Signature……………………………
(………………………….……………….)
Medical license No. ……………………..………
Date……………………..…..Time……………….
Nurse’s Name………………..…………….……..
Date……………………..…..Time……………….
Page 1/1
Post – Permanent Date: ………………………………….…..Time:………………....….…
Pacemaker Order HN.:……………………………….….……Room:………………..........
Name:……………………..…………...…Gender:………..……..…….
Date of Birth:………………………..……Age:………….………..……
Physician:…………………..……...……..MD Code:………..…..….…
Allergies:………………………………….………………………..……..
Date / Time Daily Order Continuous Order
Procedure : Paracetamol (500 Mg.) 1 Tablet PO.PRN. For Pain every 6
hours.
DDD (dual chamber) Antibiotic:……………………………………………………………
VVI (single chamber) Does…………………………………………………………………
DDDR (dual chamber rate responsive)
VVIR (single chamber rate responsive)
AICD (automatic implantable cardioverter defibrillator)
CRTD (cardio resynchronization therapy - defibrillator)
CRT-P (cardio resynchronization therapy - pacing)
Other……………………………………………………………
Access Site Right Shoulder Left Shoulder
Other……………………………………
Absolute Bed Rest for 6 Hours
Not allowed to flex Right Left Hip for 6 hours
Vital sign every 15 min. until stable
Resume previous diet
Notify Physician if
- Sysyolic BP < 90 mm.Hg - Arrhythmiaor angina
- Bleeding - severe pain in affected part
- Loss of distal pulse
EKG at Ward
Chest X-Ray Tomorrow, in the morning
Check Pacemaker ICD CRTD Tomorrow, in the morning
Follow Up OPD 1 week after Discharge
Follow Up OPD 1 Month after Discharge with Check
Pacemaker / ICD / CRTD
Keep Wound Dry 1 Week
Arm sling of the affected side for 1 Month
(ห้ามยกแขนสงู เหนือหวั ไหล)่
Physician’s Signature…………………………… Physician’s Signature……………………………
(………………………….……………….) (………………………….……………….)
Medical license No. ……………………..……… Medical license No. ……………………..………
Date……………………..…..Time………………. Date……………………..…..Time……………….
Nurse’s Name………………..…………….…….. Nurse’s Name………………..…………….……..
Date……………………..…..Time………………. Date……………………..…..Time……………….
ICD : Implantable Cardioverter Defibrillator, CRTD : Cardiac Resynchronization Therapy
Page 1/2 FM-DSA017-00
Page 1/3
Order for Pre-Angiogram / PCI Date: ………………………………….…..Time:………………....….…
HN.:……………………………….….……Room:………………..........
Name:……………………..…………...…Gender:………..……..…….
Date of Birth:………………………..……Age:………….………..……
Physician:…………………..……...……..MD Code:………..…..….…
Allergies:………………………………….………………………..……..
Date / Time Daily Order Continuous Order
Procedure : Activity: Bed rest As tolerate
Coronary Angiography (CAG)
Precutaneous Coronary Intervention (PCI) Other………………………………………………..
Coronary Angiography & Percutaneous Coronary
Intervention (CAG & PCI) Diet:………………………………………………………..………
Other……………………………………………………..……. Record: Vital Signs every………………………………hr.
1. EKG (if not done within 3-7 days) Intake/ output every…………………….….…hr.
2. Chest X-Ray (if not done within 3 months) Other………………………………….…………..
3. Labs :
Medication / Treatment :
CBC
Creatinine
BUN
Potassium (K+)
Other : …………………………………..…………….
4. Shave and Prep. ………… Groin (s) or…………. Arm(s)
5. NPO 4 Hours before Procedure (sip of water allowed)
6. Alert Physician if K+ < 3.5 or > 6.0 mmol/L or
Creatinine > 2.0 Mg/dL
7. Check Vital Sign, Distal Pulse and have patient void
Before going to the Cath Lab
8. Send the patient, together with full medical record
To the Cath Lab
9. Pre-Medication;
10. IV fluid acess;
Physician’s Signature…………………………… Physician’s Signature……………………………
(………………………….……………….) (………………………….……………….)
Medical license No. ……………………..……… Medical license No. ……………………..………
Date……………………..…..Time………………. Date……………………..…..Time……………….
Nurse’s Name………………..…………….…….. Nurse’s Name………………..…………….……..
Date……………………..…..Time………………. Date……………………..…..Time……………….
Page 1/2 FM-DSA-018-00
Order for Post-Angiogram / PCI Date: ………………………………….…..Time:………………....….…
HN.:……………………………….….……Room:………………..........
Name:……………………..…………...…Gender:………..……..…….
Date of Birth:………………………..……Age:………….………..……
Physician:…………………..……...……..MD Code:………..…..….…
Allergies:………………………………….………………………..……..
Date / Time Daily Order Continuous Order
Medication / Treatment
Procedure :
FM-DSA-018-00
CAG PCI
CAG & PCI EPS and RFA
Cerebral Angiogram Carotid Angioram
Abdominal Angiogram
Other………………………………………………..………..…
Access Site Right Groin Left Groin Other….………
Sheath left in situ to be removed at ………………….………
Removed Pressure Dressing at ………………….…….….…
Absolute Bed Rest for ………… Hours (To ……… hrs.)
With affected leg limb straight after Shealth removed.
Vital Sign every 15 min for first 2 Hrs.
Then every 30 min until stable
Check distal pulse every 15 min. for first 2 Hrs.
Then every 30 min until stable
Resume previous diet / Medication
Notify MD if
- Systolic BP < 90 mmHg
- Bleeding
- Loss of distal pulse
- Arrhythmia or angina
- Severe pain in affected part
Paracetamol (500 Mg.) 1-2 Tablet PO.PRN. For Pain every
6 Hrs.
IV fluid ;
Physician’s Signature…………………………… Physician’s Signature……………………………
(………………………….……………….) (………………………….……………….)
Medi cal license No. ……...………..……… Medical license No. …………………….………
Page 2/2 FM-DSA-018-00
Page 3/2
Physician's Order : Hemodialysis Date: Time:
HN: Room:
Name: Gender:
Age:
Date of Birth:
Physician: MD Code
Allergies:
Date/Month/Year
Mode (HD or OHDF)
Frequency (time/ week)
Duration (hr)
Dry Weight (kg)
Dialyzer (Type/ Area)
Blood Flow Rate (ml/min)
Dialysate Flow Rate (ml)
Potassium (mmol/liter)
Dialysis Calcium (mmol/liter)
solution Sodium (mmol/liter)
Bicarbonate(mmol/liter)
Anticoagulant
Heparin - Loading dose (units)
- Maintenance (units)
Clexane (ml)
Innohep (units)
Arixtra (mg)
Vascular Acess
Graft Fistula: Left Right
Double Lumen catheter
Permanent catheter
Fill Arterial…..……...ml
Volume Venous………….ml
Fill Heparin(5,000 units/ml)
Solution 4% Citrate
Other:
Intradialysis medication
Epoetin
Venofer (100 mg/5 ml)
Kidmin (200 ml)
20% Intralipid
Vitamin C (500 mg/2 ml)
Other:
Nephrologist's Signature
MD Code
Dialysis Nurse’s Signature/
Employee ID
FM-HDD-001-00
CRRT ORDER FORM Date: ………………………………….…..Time:………………....….…
HN.:……………………………….….……Room:………………..........
Name:……………………..…………...…Gender:………..……..…….
Date of Birth:………………………..……Age:………….………..……
Physician:…………………..……...……..MD Code:………..…..….…
Allergies:………………………………….………………………..……..
Day ORDER FOR ONE DAY AMOUNT ORDER FOR CONTINUATION
Hour
CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) (1)
ORDER SET
Check All Orders that Apply with a & All Handwritten Laboratory order
Orders Should be BLOCK PRINTED for Clarity
Initiate Modality : CVVHDF CVVHD CVVH SCUF Bun , Cr , Alb q …………………hr.
Electrolyte q ……..…….…….hr.
Filter Sureflux 150 Aquamax ……………...…..…………
Blood flow rate………………….…………ml/min Ca2+ q …………………hr.
Dialysate flow rate………………….……..(ml/hr) Mg2+ q …………………hr.
Replacement flow rate……………..……..(ml/hr) Phosphate q …………………hr.
Patient fluid removal…………………...…ml/hr
Call MD for clotting, bleeding, excessive or low fluid removal or iCa2+ q …………………hr.
aPTT out of range specified below
Anticoagulation (select one): None Heparin(select) ……………………………………………...…………
Citrate Bolus………….Units ……………………………………………...…………
Infusion………….……units/hour
aPTT prior to start of CRRT and then every ……….…..hours when on ……………………………………………...…………
……………………………………………...…………
……………………………………………...…………
heparin for anticoagulation, Maintain aPTT between……………………….
and………………….set
Priming Solution
Prime system with 1 Litre 0.9% NaCl with Heparin 5000 u
Prime system with 1 Litre 0.9% NaCl
Dialysate and Replacement Solutions
Note : All changes to content of dialysate and replacement solution MUST be
ordered on this preprinted order form.
0.45% NaCl…………..ml.
3% NaCl………………ml. 4% Trisodium Citrate…......…ml.
7.5% NaHCO3………..ml. Accusol - 35
Sterile water…….…….ml.
KCL……..…………mEq/L
Administer Replacement Solution Selected Above as Follows:
Post – Filter Replacement Solution………………….ml/hr
Pre – Filter Replacement Solution……………..…….ml/hr
10% Calcium gluconate………………….….ml / 24 hr
50% MgSO4………………………………..…gm / 24 hr
Physician's signature .................................................................... Physician's signature ...............................................
( , MD) ( , MD)
Medical License No. ว. ............................. Medical License No. ว. .............................
FM-HDD-003-00
Physician’s Order : Date ……………………………………..Time ……………………….
Dressing material for discharge HN. ………………………………………Room: ………………........
Name: ………………………………...…Gender………..…………..
(TDWC) Date of Birth: …………………………….Age: ………….……..……
Physician: ………………………………..MD Code…………………
Allergies: ………………………………..……………………………..
Date/ ORDER FOR ONE DAY ONLY Date/ ORDER FOR CONTINUATION
Time Time
FM-DWC-016-00
OPD IPD
Dressing material for discharge No.
Betadine solution 450 ml/bottle ………….…..
Betadine scrub 450 ml/ bottle ………….…..
Dressing set (disposable) ……………...
Betadine 30 ml/bottle ……………...
Conform 4 นวิ ้ ……………...
Gauze 3x3 4x4 2x2 ……………...
Leukostrip 2880 ……………...
Presnet 5 นวิ ้ 2 นวิ ้ ……………...
Fixomull 10x15 ( box) ……………...
Funginox sprey ……………...
Iruxal mono ……………...
Sanoskin ……………...
Fucidine cream / ointment ……………...
Fucicort cream ……………...
Nizoral cream ……………...
Meplilex border 7.5x7.5 10x10 10x30
15x15 15x20 ……………...
Appresan foam ……………...
Eucerin lotion pH 5 250 ml ……………...
Cavilon cleanser ……………...
…………………………………………………………………
…………………………………………………………………
…………………………………………………………………
…………………………………………………………………
…………………………………………………………………
Physician's signature .............................................................
( ……………………………………………, MD)
Medical License No. ว. ..................................
Pre Operative Medical Assessment Form Date: .............................................. Time ......................
HN: .................................................Room.......................
Name: ...........................................Gender......................
Date of Birth .........................................Age ..................
Physician: ......................................MD Code..................
Allergies ..........................................................................
History:
Operative Diagnosis: ……………………………………………………………………………………………………..………………………….………..……...
Proposed Surgery: ………………………………………………………………………………………………………………….……………………………...….
Classification: Minor Major Elective Emergency
Anticipated anesthesia: Local Regional General Spinal Unknown
Medical Problems
1. 4.
2. 5.
3. 6.
Current Medications:
Anticoagulant No Yes Hypoglycemic agents No Yes
Antiplatelets No Yes Beta blockers No Yes
Estrogen/Estrogen Receptor Modulator No Yes Drugs with potential withdrawal No Yes
List of current Medications 7. ……………..……………………………………………………………….…..
1. ……………..………………………………………………………………….. 8. ……………..……………………………………………………………….…..
2. ……………..………………………………………………………………….. 9. ……………..…………………………………………………………….……..
3. ……………..………………………………………………………………….. 10. ……………..…………………………………………………………………..
4. ……………..………………………………………………………………….. 11. ……………..…………………………………………………………………..
5. ……………..………………………………………………………………….. 12. ……………..…………………………………………………………………..
6. ……………..…………………………………………………………………..
Review of Systems:
1. General : Negative Positive 5. Pulmonary : Negative Positive
Fever Negative Positive Cough Negative Positive
2. ENT : Negative Positive Shortness of breath Negative Positive
Nasal Obstruction Negative Positive Wheezing Negative Positive
3. Neck : Negative Positive Sputum production Negative Positive
4. Cardiovascular: Negative Positive 6. Gastrointestinal Negative Positive
Chest Pain Negative Positive 7. Genitourinary Negative Positive
Irregular Heart Beat Negative Positive LMP (Female only) …………………………..
Heart Attack < 6 months Negative Positive 8. Hematology/Lymphatic Negative Positive
Heart Failure Symptoms Negative Positive 9. Musculoskeletal Negative Positive
Claudication Negative Positive 10. Neurological Negative Positive
Comments :
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Allergies : Drugs As listed above…………………….…………………. New…………………………………………………………………..
Latex No Yes
Personal and Family History of adverse reaction to anesthesia No Yes FM-ORD-016-00
Habits:
Tobacco No Yes …………………… pack - year ; Current No Yes
Alcohol No Yes
Illicit drug No Yes
Page 1/2
Pre Operative Medical Assessment Form Date: .............................................. Time ......................
HN: .................................................Room.......................
Name: ...........................................Gender......................
Date of Birth .........................................Age ..................
Physician: ......................................MD Code..................
Allergies ..........................................................................
Physical Examination:
Temp………………… ºC Pulse……………/min RR……………/min Weight………………Kg. Height………………cm.
Normal Abnormal Normal Abnormal
1. General Appearance 5. Cardiovascular :
Cyanosis Rate and Rhythm
Pallor Heart sounds
Nutritional status Heart murmur
2. Mental Status Peripheral pulses
3. Neck 6. Abdomen:
Carotid arteries 7. Neurological:
Jugular venous distention (JVD) 8. Extremities:
4. Chest and Lungs:
Wheezes
Crackles
Comment :
………………………………………………………………………………………………………….……………………………………………………………………….….……
…………………………………………………………………………………………………………………………………………………………………………….……….……
…………………………………………………………………………………………………………………………………………………………………………..………………
Investigation :
Hb Hct WBC Plt FPG Cr Na K Alb PT/PTT Others
CXR Normal Abnormal
EKG Normal Abnormal
Other investigation : …………………………………………………………………………………………………………………………………………………
Assessment :
1. Cardiovascular and Pulmonary Risk : Low Moderate High
2. Risk of bleeding : Low Moderate High
3. Risk of DVT : Low Moderate High
4. ASA classification : ………………………………………………………………………………………………………………………………………………..
5. Comorbidities: …………………………………………………………………………………………………………………………………………..……………….….…..
………………………………………………………………………………………………………………………………………………………………………….………….……
………………………………………………………………………………………………………………………………………………………………………….………….……
Recommendation :
1. Proceed with surgery : Yes No
2. Perioperative Management :
……………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………….………………..……..…
………………………………………………………………………………………………………………………………………………………………………………..…..…..…
Physician’s Signature………………………………………………………….MD Code………………………Date………………………..Time………..……
Page 2/2
FM-ORD-016-00
Pre-operative order Date ……………………………………..Time ……………………….
Endovascular therapy for PAD HN. ………………………………………Room: ………………........
Name: ………………………………...…Gender………..…………..
Date of Birth: …………………………….Age: ………….……..……
Physician: ………………………………..MD Code…………………
Allergies: ………………………………..……………………………..
Date/ Date/ ORDER FOR CONTINUATION
Time ORDER FOR ONE DAY ONLY Time FM-DSA-010-00
Set OR for endovascular therapy for PAD on ....../......./ 20...... ,
start at .......... : .......... including:
1.1 □ Percutaneous balloon angioplasty (PTA) +/- stenting of
□ right □ left leg arteries □ aorto - iliac lesion □ other .................
1.2 □ Percutaneous mechanical thrombo - aspiration/thrombectomy
of □ right □ left □ SFA □ popliteal artery □ BTK (below-the-knee)
arteries □ aorto-iliac lesion □ other ...........................
1.3 □ Catheter-directed thrombolysis (CDT) of □ right □ left □ SFA
□ popliteal artery □ BTK (below-the-knee) arteries □ aorto-iliac
lesion □ other ...............
1.4 □ Other procedure (s) .....................................................................
…………………………………………………………………………………
2. Percutaneous arterial access technique under portable ultrasound
guidance:
2.1 □ Retrograde access (Uphill puncture) through □ right CFA
□ left CFA □ right brachial artery □ left brachial artery
□ other..................................................................................................
2.2 □ Antegrade access (Downhill puncture) through □ right CFA
□ left CFA □ right brachial artery □ left brachial artery
□ other..................................................................................................
3. Prepare skin of
□ Lower abdomen and both groins □ right leg □ left leg
□ right arm □ left arm
4. NPO started from ...... : ....... (6 hours prior to starting the operation)
5. Surgeon: Assistant (s):
□ Chumpol Wongwanit, MD (17565) □
□ Sutheekanit Hathapornsawan, MD (22986) □
□ Kiattisak Hongku, MD (27504) □
□ Nuttawut Phuangphangam, MD (30865) □
□ Tossaphol Prapassaro, MD (39286) □
□ Kanin Phreukprasert, MD (41077) □
□ Other .............................................................. (..........................) □
□ Other .............................................................. (..........................) □
□ Other .............................................................. (..........................) □
(*หมายเหตุ ถ้าเป็ น Surgeon ให้ tick box ส่ีเหล่ยี มด้านหน้า ถ้าเป็ น
Assistant (s) ให้ tick box ส่เี หล่ียมด้านหลัง)
Page 1 / 2
Pre-operative order Date ……………………………………..Time ……………………….
Endovascular therapy for PAD HN. ………………………………………Room: ………………........
Name: ………………………………...…Gender………..…………..
Date of Birth: …………………………….Age: ………….……..……
Physician: ………………………………..MD Code…………………
Allergies: ………………………………..……………………………..
Date/ Date/ ORDER FOR CONTINUATION
Time ORDER FOR ONE DAY ONLY Time FM-DSA-010-00
6. Anesthesiologist (s):
□ Prasert Sawadviphachai, MD (20529)
□ Other .............................................................. (..........................)
7. Scrub nurse(s)
□ Monrudee Chengsutha
□ Vichittra Sangkaho
□ La-ongdao ..............................................
□ Other ................................................................................................
8. Pre-operative prophylactic antibiotic (s)
□ Cefazolin 2 g
□ Clindamycin 600 mg
□ Other ................................................................................................
intravenous drip 30 minutes prior to start operation
□ As infectious disease (ID) specialist recommended
9. □ Retain Foley urinary catheter No. ........
10. Please notify medical representatives of the following company
(ies):
□ Biotronik □ ABBOTTS □ Medtronic □ Boston Scientific
□ Other ..................................................................................................
□ Other ..................................................................................................
For preparing the following devices:
□ Introducer sheaths □ Wires □ PTA Balloon catheters
□ Cutting balloon catheters □ Drug-coated balloon (DCB) catheters
□ Stents □ Drug-eluting stents (DES) □ Covered stent
□ Athrectomy devices ...........................................................................
□ Vascular closure devices
□ Portable Ultrasound
□ Actilyse (rt-PA) 50 mg. 1 Vial
□ Other ..................................................................................................
□ Other ..................................................................................................
□ Other ..................................................................................................
Physician's signature ............................................................................
( , MD)
Medical License No. ว. ...............................
Page 2 / 2
OR Schedule Order Date: Time:
HN: Room:
Name: Gender:
Age:
Date of Birth: MD Code
Physician:
Allergies:
Surgery / Procedure…………………………………………..Scheduled Date…………………….Time………………...hr.
Diagnosis……………………………………….………………...Estimate Surgical Time……………...……………………hr.
Surgeon / Doctor……………………………………………….Assistant……………………...…..……………………..………
Anesthesiologist (If requested)………………………………………………………………………………………………..…….
Daily Order Date/ Investigation
Time(hr.)
- NPO : Date……../ ……../…….. Time……….hr. PART A: Mandatory for general or regional anesthesia
- Pre-op consultation for Medical clearance Medical Clearance is optional for local anesthesia
and emergency patient
O NO O Yes By Dr………………. 1. Patient Age ≤ 15 years old —> Ped. Consult
- Post Operation plan transfer to higher level of care - CBC
2. Patient Age > 15 - 40 years old
O Intermediate Care Unit (specify) - CBC
O Critical Care Unit (Specify) 3. Patient Age > 40 - 60 years old —> Optional Med.
◻ Special Equipment : (please specify) Consult
1. ……………………………………………………….. - Blood sugar (Fasting / Non-fasting)
2. ……………………………………………………….. - CBC
3. ……………………………………………………….. - Creatinine
- EKG
Physician's Signature …………………………….…… - CXR
Medical License number ………………………….…. - Urine Analysis
4. Patient Age > 60 years old, or Patient at any age
with active underlying disease —> Mandatory Med.
Consult
(eg. DM, HTN, CAD, Asthma, Functional Thyroid
Disease, COPD, Chronic renal failure, Chronic liver
disease, Coagulopathe, Heavy tobacco use)
- Blood sugar (Fasting / Non-fasting)
- CBC
- Creatinine
- EKG
- CXR
- Urine Analysis
5. Additional laboratory tests:
Anti HIV
6. Other (if any)………………………………………………
PART B:
Frozen section Time………………… hr.
Pathologist (If requested) Dr……………………………….
OPD Clinic / IPD Nurse……………………………… Received schedule order by (OR Nurse)……………………………
Date………...………..Time……………..hr. Date………...………..Time……………..hr.
FM-ORD-007-00
Operative Record Excisional Date: ………………………………….…..Time:…………..……..….…
Debridement with STSG HN.:……………………………….….……Room:………………..........
Name:……………………..…………...…Gender:………..……..…….
Date of Birth:………………………..……Age:………….………..……
Physician:…………………..……...……..MD Code:………..….….…
Allergies:………………………………….………………………….…..
Operative Date .................................................................................................Operation Start ..................................Finish...........................
Pre-Operative Diagnosis ...................................................................................Operative Diagnosis................................................................
Operation: Excisional Debridement with STSG (Split thickness skin graft) Position: Supine
Surgeon: .................................................... Assistant:........................................................Anesthesiologist:....................................................
Scrub Nurse ............................................... Circulating Nurse............................................Anesthesia.............................................................
Specimen for investigation No Yes................................................................................................................................
Estimated Blood Loss............... ml Blood Transfusion No Yes ...............................................................................................
Complication No Yes ..................................................................................................................................................................
Procedure/ Finding......................................................................................................................................... .....................................................
Implants...................................................................................Donor site:..........................................................................................................
Procedure:
The patient was placed in supine position. Skin was prepped and painted in sterile technique.
The necrotic tissue and slough was removed by...............................................................................................................................................
Bleeding was checked and stopped by cautery.
STSG was harvested by dermatome from.....................................................................................................................and graft was meshed.
Then graft was placed at wound and fixed with skin stapler/sutured with nylon no. .........................................................................................
Wound was dressing with...................................................................................................................................................................................
No immediate complication. Then the patient was transferred to recovery room.
Surgeon........................................................................Medical license No.................................Date................................. Time......................
FM-DWC-002-00
Preoperative Assessment Date: .................................................... Time ......................................
HN:.........................................................Room.....................................
Name:....................................................Gender...................................
Date of Birth ........................................Age ........................................
Physician:........................................MD Code................................................
Allergies .....................................................................................................
Surgeon : Anesthesiologist :
Date of evaluation Time Diagnosis Physical Examination
Date of Surgery Time Schedual Procedure
Patient History
Underlying disease Vital Sign Temp BP mmHg. PR /min.
HT DM Concious Level Alert/Responding Weight kg.
COPD Asthma TB Drowsiness Height cm2
MI/CAD CHF Unable to responnd BMI kg/m2
Thyroid disease GCS E V M
CRF (HD /week) Airway Assessment
CVA/Stroke Artificial No ETT Tracheostomy
Functional Class <4METS >4METS Mallampati 1 2 3 4
TM distance Normal <6cms.
(>4METS : Climb a flight of stairs or walk up a hill? Run a short distance?) Mouth Open Normal <3cms. X=Missing
Patent Nares Normal Not patent C=Caries
Pregnancy No Yes LMP / / CR=Crown
R=Removable denture
Allergy No Yes B= Bridge
M=Mobility
Habit No Smoke /pack year Prominent Incissior Normal Prominent
Alcohol /month Limit Neck ROM Normal Limit motility
Drug abuse Dental Problem No Yes
Previous Anesthesia
No Yes Contract Lens used No Yes
Previous Anesthetic Complication
No Yes Respiratory system Normal
Current Medication
CVS system Normal
Systemic Review
CNS Normal Seizuer Headache Weakness Numbness Abdomen Normal
CVS Normal Chest pain Edema
Palpitation Dyspnea/Orthopnea Extremities Normal
RS Normal URI Cough Sputum Distress
GI Normal Jaundice Anorexia Cirrhosis Neurology Normal
GU Normal Renal insufficiency/Failure Dialysis Site
Nocturia Polyuria Retention IV cannulation Site
COAG Normal Bleeding tendency Easy Bruise
Anesthetic Assessment Laboratory Investigation
ASA Physical Status 1 2 3 4 5 E CBC Hb BUN TP/Alb
Problem List Hct Cr AST
Plt Na ALT
WBC K ALP
Specific Risk Concern UA Cl TB/DB
CO2 Others
Anti_HIV
Anesthetic technique Coag PT
Disscussed with patient/relatives/guardians:Agreed with PTT HBsAg
GA Mask LMA ETT TIVA TT VDRL
T Risk of PONV,Sorethroat,Eye injury,Dental injury PNB INR
RA SB EB CSE CXR
T Risk of PONV,Headache,Itching,Back pain,Numbness EKG
Landmark for RA
Normal Local infection Abnormality
Anesthetic Preparation
NPO Time Monitoring Blood component Day Surgery No
Instrucon NPO time to patient/relative/guardians:Risk of Aspiration Basic(EKG,NIBP,SPO2) PRC units Yes TDischarge with Companion
Medical Clerance Indicate ETCO2 FFP units Pain Control
Urine Platelet units
IBP Unnecessary Epidural
Premedication CVP Oral Intracheal
IV PNB
TYes Note : Transfer IM PCA
Inform Consent No PACU ICU
Anesthetic plan,technique,alternative,benefit,complcation,risk,outcome
and post operative care were explained to patient/relative/guadians Anesthesiologist's Signature :
FM-ANE-002-00
Operative Note Date: Time:
HN: Room:
Name: Gender:
Age:
Date of Birth: MD Code
Physician:
Allergies:
Pre – Operative Diagnosis : ……………………………………………..………….…………………………………………….….…...
Post - Operative Diagnosis : …………………………………………….…………………………………………………………….…..
Operation : …………………………………………………………………...……………………………………………….………..…….
Surgeon : …………………………………………...………….Surgeon Assistant : …………...………………………………..………
Anesthesiologist : ……………...………………………………Instrument Nurse : ………………………………………..……..……..
Anesthesia Operative Time……………………...…...…Estimated Blood Loss…………………………………….……...
Sponge Count Correct :……………………….…...…………Specimen for Investigation :………..………………………..……......
Physician’s Signature………………..……………….....MD Code………………………date…………………….Time……………….
Page 1/3 FM-ORD-004-00
Operative Note Date: Time:
HN: Room:
Procedure (Continued) : Name: Gender:
Age:
Date of Birth: MD Code
Physician:
Allergies:
Physician s Signature .. .....MD Code date .Time .
Page 2/3 FM-ORD-004-00
Operative Note Date: Time:
Inplant / Prosthesis : HN: Room:
Name: Gender:
Age:
Date of Birth: MD Code
Physician:
Allergies:
Physician s Signature : ... .. .
Medical license number : ..
Date : Page 3/3 .. ..
FM-ORD-004-00
Procedure Notes Date ……………………………………..Time ……………………….
HN. ………………………………………Room: ………………........
Name: ………………………………...…Gender………..…………..
Date of Birth: …………………………….Age: ………….……..……
Physician: ………………………………..MD Code…………………
Allergies: ………………………………..……………………………..
Procedure :………………………...…………………………………………………………………………………………………………………………
Indication (s) :……………………………………..…………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
Technique of Anesthesia (Check one or more that is (are) applicable);
Local Anesthesia
Lidocaine…………………….……………………..…….% Amount……………………… ml.
Bupivacaine……………………………………….….…. % Amount……………………… ml.
Others……………..………………………………….….. % Amount……………………… ml.
Minimal Sedation: Drug(s) and dose(s)………………………………………………………………………………………….……….…………..
Moderate Sedation: Drug(s) and dose(s)………………………………………………………………………………………………….…………
Others (please specify)……………………………………………………………………………………………………….………………………..
Procedure Physician:………………………………………………………………………………………………………………………………………..
Procedure and findings:…………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
Estimated Blood Loss: ........................................ml Minimal Blood Loss
Drains: No Yes ……………………………………………………………………………………………………………………...
Specimen(s): No Yes ……………………………………………………………………………………………………………………...
…………………………………………………………………………………………………………………………………………………………………
Periprocedural Complications: No Yes ………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………………
Physician’s Signature…………………………………………………………….MD Code…………………………Date………………Time………..
FM-ORD-017-00
Operative Record Date: ………………………………….…..Time:…………..……..….…
Excisional Debridement HN.:……………………………….….……Room:………………..........
Name:……………………..…………...…Gender:………..……..…….
Date of Birth:………………………..……Age:………….………..……
Physician:…………………..……...……..MD Code:………..….….…
Allergies:………………………………….………………………….…..
Operative Date .................................................................................................Operation Start ..................................Finish...........................
Pre-Operative Diagnosis ...................................................................................Operative Diagnosis................................................................
Operation: Excisional Debridement Position: Supine
Surgeon: .................................................... Assistant:........................................................Anesthesiologist : ..................................................
Scrub Nurse ............................................... Circulating Nurse............................................Anesthesia.............................................................
Specimen for investigation No Yes...............................................................................................................................................
Estimated Blood Loss............... ml Blood Transfusion No Yes ...........................................................................................
Complication No Yes ..................................................................................................................................................................
Procedure/ Finding..............................................................................................................................................................................................
Implants.................................................................................................................................................................................... ...........................
The depth of the debridement Skin Subcutaneous tissue Fascia Muscle Bone Other.............................
Procedure:
The patient was placed in supine position. Skin was prepped and painted in sterile technique.
The necrotic tissue and slough was removed by...............................................................................................................................................
Bleeding was checked and stopped by cautery.
Wound was dressing with...................................................................................................................................................................................
No immediate complication. Then the patient was transferred to recovery room.
Surgeon........................................................................Medical license No.................................Date................................. Time......................
FM-DWC-003-00
Intraoperative Record Date ……………………………………..Time ………………………….
HN. ………………………………………Room: ………………............
Name: ………………………………...…Gender………..……………..
Date of Birth: …………………………….Age: ………….………..……
Physician: ………………………………..MD Code……………………
Allergies: ………………………………..………………………………..
Preinduction Assessment Problem List Weight Kg. BP mmHg Diagonosis
Premedication Helght cms. PR /min Procedure
ASA physical status : BMI Kg./m² SpO2 %
NPO time RA On Oxygen
123456E
Difficlu Airway : Yes No
Time Oxygen Total Remarks :
Gas Nitrous
Sevo
Propofol
Succinyl
Morphine
Fentanyl
Dormicum
Dtug
Monitor
v ETCO2
SBP SpO2
°C 220
40
^ 200
DBP 38 180
. 36 160
34 140
Pulse
@ 32 120
Start 30 100
Op
X Start 28 80
Anes 26 60
Ø End Anes 40
20
R = Reverse
Atropine Mg
Qutput Intake Neostigmine Mg
Cesarean Section
Time Delivery
:
Gender
□ Male □ Female
Technique □ General Anesthesia □ Regional Anesthesia □ TIVA □ MAC □ Combined GA + RA □ Other
General Anesthesia With Breathing System Regional Anesthesia Position Monitor
□ Mask □ LMA No. □ Tracheostomy □Circle □Spinal needle □Supine □NIBP,PR,SpO2,EKG
Type □Jackson Ree □Epidural Catheter □Late R LL □ETCO2
□ ETT Route : □Oral □Nasal □Bain □CSE Attempt □Prone □Urine
□Awake intubation Laryngoscopic blade No. Ventilation □Lithotomy □Temp
□Spontaneous □PNB Agent □Jacknife □Airway Pressure
□Inhalation intubation □Machintoch □Assist
□Control Technique/Approach/Level/Position □Trenderlenburg □IBP
□Rapid seqence □Miller □Jet
Breath Sound □Reverse Trend. □CVP
□Already intubation □Mccoy □TEE
□Depol MR Intubation Tube No. □cuff □uncuff Eye care □PCWP
□Pads □Eso steth
□Blind □PVC Attempt □Ointment Tranfer Respiration Consciousness Transfer To □Precodial Steth
□Direct Laryngoscopy □REA Depth □Tapes Airway Support □Spontaneous □Alert □PACU □PNS
□Fiberoptic □MLT □No □None □Assist □Arousal on calling □ICU
□Glidescope □Reinforced □airway □Control □Non-respond
Difficult □ETT
□Yes □Trach
LV
Anesthetic Time……………………………...……………….. Anesthesiologist's Signature……………………………………………………………………………………………..
FM-ANE-003-00
Post Anesthetic Record Date: .................................................... Time ........................................
HN:.........................................................Room.......................................
Date : Name:....................................................Gender......................................
Post-op Diagnosis : Date of Birth ...........................................Age ..........................................
Post-op Procedure : Physician:.............................................MD Code...........................................
Surgical Team : Allergies ......................................................................................................
TIME Anesthetic Technique Intake/output
Oxygen
Anesthetic Agent Complication/Specific concern
EKG Anesthetic Team :
SPO2
°C 220 Patient Status on Arrival Consciousness
40 Blood Pressure mmHg [ ] Alert
Pulse Rate /min [ ] Arousal on calling
200 Respiratory Rate /min [ ] Unconsciousness
38
Breathing pattern Airway Support
180 [ ] Spontaneous/Normal Oxygen [ ] None
36 [ ] Abnormal Saturation [ ] Oral Airway
Thermoregulation % [ ] Nasal Airway
160 [ ] None [ ] Endotracheal Tube
34 [ ] Blanket / Force Air Warmer Oxygen Supplement
Regional Anesthesia [ ] None
140 Anesthetic Level………………. [ ] Cannula…..…...LPM
32 [ ] Have Catheter : Site………….. [ ] Mask………..…LPM
[ ] Off at recovery room & catheter tip intact at time…................…............…………...…
120 [ ] Retained To ward for intermittent / continue infusion……….........................………….
30
Systolic BP Status/Problem Treatment
100 v
28
Diastolic BP
80 ^
26
Pulse· Rate
60 MPearensAsrutererial
40
20 x
TOTAL
INTAKE
ALDERT SCORE OUTPUT Urine
Drain
30 minutes 60 minutes 90 minutes 2 hours Before Discharge
Activity
Respiration
Circulation
Conscious
SPO2
Nausea/Vomit
Pain
Bleeding
TOTAL SCORE
Discharge Criteria Check List YES NO Condition Before Discharge mmHg
Alert and oriented as appropriate for age return to baseline status prior to vital Sign BP /min
anesthesia/sedation %
Absence of Respiratory distress ; Respiratory effort return to baseline for age Pulse Rate
Able to ambulate or perform movement consist with developmental age or baseline SPO2
No nausea, vomiting or dizziness (OPD)/Minimal nausea, vomiting or dizziness(IPD) Consciousness
Pain score < 4
Vital sing and saturation stable (return to baseline or appropriate for age) Transfer To
Aldrete score 8 or return to pre-procedure baseline □ WARD □ ICU
No evidence of surgical or procedure complication
Stay in recovery area at least 1 hour □ Home/Discharge with :
RN's Signature………………………………………………………….………………… Recovery Room Time :
Discharge by Anesthesiologist……………………..……………………………
FM- ANE-004-00
Post - operative order for Date ……………………………………..Time ……………………….
Angioplasty HN. ………………………………………Room: ………………........
Name: ………………………………...…Gender………..…………..
Date of Birth: …………………………….Age: ………….……..……
Physician: ………………………………..MD Code…………………
Allergies: ………………………………..……………………………..
Date/ ORDER FOR ONE DAY ONLY Date/ ORDER FOR CONTINUATION
Time Time
Post – op Rx. for Percutaneous balloon angioplasty of …... Diet
…………………………………………………………..…………
………………………………………………………………..…… Record เหมือนกอ่ นผา่ ตดั
Routine Post – op care Medication
Record Vital signs
ASA (81 mg.) 1 x 1 pc.
q 15 min x 4 then
q 30 min x 4 then ASA (100 mg.) 1 x 1 pc.
q 1 hr. x 4 then
q 4 hr. until stable Plavix (75 mg.) 1 x 1 pc.
Monitor Arterial Doppler signal at ……………………….……..
q 1 hr. x 6 then Paracetamol (500 mg.) 1 tab prn for pain ,
q 2 hr. x 4 then
q 4 hr. q 4 hr.
Observe bleeding & hematoma at ………………….……….…
Observe acute limb ischemia of …………………………….…. Tramal (50 mg.) 1 cap prn for severe pain ,
Observe Pain
Observe Pallor (Pale) q 6 hr.
Observe Poikilothermia (Coldness)
Observe Sensory loss of …………… foot เปิดทาความสะอาดแผลตามที่ Dr. Borripatara
Observe Motor deficit of …………… foot
หลงั Post – op day 1 at 7.00 am. เหน็ สมควร
CBC , BUN , Cr , Electrolyte , Ca , Mg , PO4 , CPK , LFT ,
Trop – T , EKG 12 leads , CXR Vacuum drain record
Monitor urine output keep 0.5 ml/ kg/hr
……………………………………………………...………………. ………………………………………………………
……………………………………………………...……………….
……………………………………………………...………………. ………………………………………………………
………………………………………………………
………………………………………………………
………………………………………………………
………………………………………………………
………………………………………………………
………………………………………………………
………………………………………………………
………………………………………………………
………………………………………………………
………………………………………………………
………………………………………………………
………………………………………………………
Physician's signature .......................................................................... Physician's signature ..................................................
( , MD) ( , MD)
Medical License No. ว. ............................. Medical License No. ว. .............................
FM-DSA-011-00
Post – operative order Date ……………………………………..Time ……………………….
for Spinal / Epidural Morphine HN. ………………………………………Room: ………………........
Name: ………………………………...…Gender………..…………..
Date of Birth: …………………………….Age: ………….……..……
Physician: ………………………………..MD Code…………………
Allergies: ………………………………..……………………………..
Date ORDER FOR ONE DAY ONLY Date ORDER FOR CONTINUATION
Time Time
Post – operative order for Spinal / Epidural Morphine FM- ANE-005-00
1. Patient receive spinal / Epidural Morphine……………..mg.
Time………………..Date………………….
2. ห้ามให้ยาระงบั ปวดทเี่ ป็ น Narcotics, ยากลอ่ มประสาทหรือยานอน
หลบั (ยกเว้นได้รับอนญุ าตจากวิสญั ญีแพทย์) ภายในเวลา….............ชม.
หลงั จากเวลาทผี่ ้ปู ่ วยได้รับ Spinal หรือ Epidural Morphine
3. Stock Narcan 1 amp. (0.4 mg/ml)
4. Record respiratory rate and sedation score hourly for 12 hours
and then every two hours for 12 hours.
5. If RR ≤ 10 bpm. or sedation score ≥ 2 → wake up the patient,
oxygen mask 8 LPM and notify physician (Doctor) immediately
6. Medication for Nausea or vomiting
Plasil 10 mg. IV prn q 6 hr.
Ondansetron 4 mg. IV prn q 4 hr.
……………………………………………………………….…..……
7. ให้นอนราบ……………...ชม. ครบเวลา……………...น.
8. Medication for pruritus or itching
Chlorpheniramine 10 mg. IV prn q 6 hr.
3.5 Nubain………….mg. IV prn q 4 hr.
…………………………………….…………………………………..
9. ให้รายงานแพทย์…………………….........…...........…………………
ถ้าผ้ปู ่ วยเริ่มเจบ็ แผลผ่าตดั หรือ pain score ≥ 4 กอ่ นเวลา…............….น.
วนั ท่ี………………….
10. Medication for pain as rescue…………………..………………....
………………………………………………………………………….……..
Start time………….…..Date…………………..
11. Keep IV access (IV fluid or IV Heparin lock) at least
Time……………….…..Date………………..….
12. Voiding
Retain Foley Catheter at least Time….………..Date……..……..
Single intermittent urinary catheterization (สวนยางแดง)
if patient can not urinate q……….….hr.
Physician's signature…………………………………………….…
(…………………………………………..…..)
Medical License No………………………………
Date………….……….Time……………..……….
Hand off Form Operative Room Date: Time:
HN: Room:
Name: Gender:
Age:
Date of Birth: MD Code
Physician:
Allergies:
Date……../……../…….. From Department………………to…………………. From Department………………to………………….
Situation …………../…………../………….. …………../…………../…………..
- Sender/ Positon …………../…………../………….. …………../…………../…………..
- Receiver/ Position/
Time
- Reason for transfer Admit Transfer to higher level of care Admit Transfer to higher level of care
Operation Investigation Operation Investigation
Consult Other……………………... Consult Other……………………...
Background Same………………………………..……………...……
- Presenting Complaint ……………………………………………………. ……………………………………..………………..…...
…………………………………………………….
- Past Medical History None Cardiovascular disease None Cardiovascular disease
Assessment Chronic Kidney disease Dyslipidemia Chronic Kidney disease Dyslipidemia
- Vital Signs
Diabetes Mellitus Hypertension Diabetes Mellitus Hypertension
Stroke Other…………….……...…… Stroke Other…………..………………
Temp.: ………………°C RR………………/min Temp.: ………………°C RR………………/min
Pulse ………./min Regular Irregular Pulse ………./min Regular Irregular
BP……………......mmHg. O2Sat………. % (If indicated) BP……………......mmHg. O2Sat……. % (If indicated)
Recommendation None None
- Special Bleeding precaution Bleeding precaution
Care/ Precaution Hemodynamic condition Hemodynamic condition
Isolation Precaution Isolation Precaution
Documentation Strict Fall Precaution Strict Fall Precaution
Special equipment to be prepare (if any) Special equipment to be prepare (if any)
Oxygen: Oxygen:
Cannula……………. LMP Cannula……………. LMP
Mask with bag…….. LMP Mask with bag…….. LMP
Collar mask ……….. LMP Collar mask ……….. LMP
Infusion Pump/ Syringe Pump Infusion Pump/ Syringe Pump
Ventilator setting mode………………….. Ventilator setting mode…………………..
VT…..…...ml. Rate…..….. Fi O2 ………. VT…..…...ml. Rate…..….. Fi O2 ……….
OPD Card IPD Card Film OPD Card IPD Card Film
Other…………….………....…… Other…………….………....……
FM-ORD-008-03
SURGICAL PATHOLOGY Date: Time:
REPORT HN: Room:
Name:
Date of birth: Gender:
Physician: Age:
MD Code
Allergies:
Order Number : …………………………………………….……………… Date/time………………………….………….………
Surgical Pathology Number : ………………………..………….…………Date/Time…………….……………….……...………
Attending Physician: ………………………………………….…….………Services……………………………………...….……
Consulting Physician: ……………………………………………….…...…Services……………………………………....………
CLINICAL HISTORY :
ENTIRELY SUBMITTED :
MOCROSCOPY :
DIAGNOSIS:
Diagnosed by:
Physician’s Signature:……………………………….………MD Code………….…………Date ……....…..…Time….......….
FM-ORD-015-00
CYTOPATHOLOGY REPORT Date: Time:
HN: Room:
Name:
Date of birth: Gender:
Physician: Age:
MD Code
Allergies:
Order Number : …………………………………………….……………… Date/time………………………….………….………
Cytology Number : ……………………………………………….…………Date/Time…………….……………….……...………
Attending Physician: ………………………………………….…….………Services……………………………………...….……
Consulting Physician: ……………………………………………….…...…Services……………………………………....………
CYTOLOGIC EVALUATION:
SATISFACTORY FOR EVALUATION:
GENERAL CATEGORIZATION:
DIAGNOSIS:
Diagnosed by:
Physician’s Signature:……………………….………MD Code…………………Collection Date ……....…..…Time….......….
**** Your Cervical Cancer Screening (Pap Test) was done on Date……………………………………...……….……………
The result of the test is:
Normal-Should come back for the same test in …………………………………..…………………..…….………………..
Slightly abnormal-Repeat test in …………………………………………..………………….………………………..………
Positive-Come back to see a doctor as soon as possible
FM-ORD-014-00
Pap Test (Thin prep Pap Test) Report Date: ………………………………….…..Time:………………....….…
HN.:……………………………….….……Room:………………..........
Name:……………………..…………...…Gender:………..……..…….
Date of Birth:………………………..……Age:………….………..……
Physician:…………………..……...……..MD Code:………..…..….…
Allergies:………………………………….………………………..……..
ตามที่ทา่ นได้รับการตรวจภายใน (Your cervical cancer screening (Thin prep Pap test) was done on)
เมือ่ วนั ท่ี (Date)………………………….. เดือน (Month) ………………………….. ปี (Year) …………………………..
ผลการตรวจ (The result of the test)
ปกติ (Normal)
ผิดปกติเลก็ น้อย เนื่องจากมกี ารอกั เสบในชอ่ งคลอด หรือบริเวณปากมดลกู
(Slightly abnormal due to inflammation in Vagina or Cervix)
พบเซลล์ผิดปกตทิ ่ีปากมดลกู (Abnormal cells finding)
คาแนะนา (Recommendation)
ตรวจหามะเร็งปากมดลกู ทกุ 1 ปี (Annual Thin prep Pap test every year)
ตรวจหามะเร็งปากมดลกู ซา้ (Repeat Thin prep Pap test) 3 เดือน (months) 6 เดือน (months)
พบแพทย์เพ่อื รักษา (See a doctor for further treatment)
พบแพทย์ทนั ทเี ม่อื ได้รับจดหมาย (See a doctor as soon as possible)
อ่นื ๆ (Others)………………………………………………………………………………………………………………………
Physician’s Signature……………..………………………..
(…………………..……………….., MD)
Medical license No. …………………………….
Date/Month/Year ……..…/……..…/……..…
แจ้งผลโดย(Reported by) จดหมาย (Mail) โทรศพั ท์ (Telephone number)......................................................................
ผ้ปู ่ วย (Patient) E-mail……………………………………………………………………………..
นดั ครัง้ ตอ่ ไปวนั ที่ (Next appointment)…………………………………………………………..……เวลา (Time)………………………………
ลงชื่อผ้รู ับนดั (Officer’s name)……………………………Employee ID……………………………ตาแหนง่ (Position)………………………
แจ้งผลการตรวจวนั ท่ี (Report date)……………………………………………………………...……เวลา (Time)…………………………...…
ผ้แู จ้ง (Officer’s name)………………………………..…. Employee ID……………………………ตาแหนง่ (Position)………………………
หมายเหตุ (Remark) : ติดตอ่ ผ้ปู ่ วย 2 สปั ดาห์ตอ่ เนือ่ งกนั ไมส่ ามารถติดตอ่ ได้เนอ่ื งจาก (Been trying to contact patient for 2 consecutive
weeks but failed to reach her due to) ………………………………………………………….……………….………………………………
แจ้งแพทย์เจ้าของไข้รับทราบ (Already informed attending physician)
FM-PHC-004-00
ตารางตามผล Culture Date: ………………………………….…..Time:………………....….…
วันท่สี ่ง วันท่ตี าม ชนิดท่สี ่ง HN.:……………………………….….……Room:………………..........
Name:……………………..…………...…Gender:………..……..…….
Date of Birth:………………………..……Age:………….………..……
Physician:…………………..……...……..MD Code:………..…..….…
Allergies:………………………………….………………………..……..
ผล Culture Start ATB Off ATB
FM-DWC-012-03
ตารางตามผล ESR & hs - CRP Date: ………………………………….…..Time:………………....….…
HN.:……………………………….….……Room:………………..........
Name:……………………..…………...…Gender:………..……..…….
Date of Birth:………………………..……Age:………….………..……
Physician:…………………..……...……..MD Code:………..…..….…
Allergies:………………………………….………………………..……..
วันท่สี ่ง วันท่ีผลออก ผล ESR ผล hs - CRP หมายเหตุ
FM-DWC-013-03
Critical Care Laboratory ResultsChemistryDate : ……………………………… Time : ………………………
HN : ……………………………….. Room : …………………….
DateHematology Name : …………………………….. Gender : ………………...
Time Date of Birth : ………………...…… Age : ………………………
GlucoseCardiac Physician : ………………………… MD code : ………………..
BunProfile Allergies : …………………………………………………………..
Cr./GFR
Uric acidLiver Profile FM-ICU-002-00
Na Cl
K CO2ABG
Ca Mg
Po4
WBC
Hb Hct
Platelets
D-Dimer
PT
PTT
INR
Fibrinogen
CK-MB mass
Troponin T
Amylase/Lipase
LDH
CPK
Ammonia
Chol/Trig
alb/globulin
TB/Direct bilirubin
alk phos
SGOT/SGPT
Gamma GT
pH.
PCO2
PO2
O2 Sat
BE
HCO3
Lactate
RN’ Signature/
Employee ID
HBOT 1st Assessment Form Date ……………………………………..Time ……………………..…...
HN. ………………………………………Room: ……………………......
Diagnosis: Name: ………………………………...…Gender………..………….…..
Indication: Date of Birth: …………………………….Age: ………….……..………
HPI: Physician: ………………………………..MD Code………………….…
Allergies: ………………………………..…………………….………......
U/D:
Past Medical History:
PE: Unremarkable
ENT Examination: ❑ Tympanic membrane intact both ears
CXR : ❑ Others : ………………………………………………………………..……………..……………………..
❑ Unremarkable ❑ Pacemaker: ……………………………………………………………………..
TCOM Pre-HBOT ❑ Date: N/A
Contraindication Check - List ❑ No Untreated Pneumothorax
❑ No Untested Pacemaker
❑ No Med as follow : (Doxorubicin (Adriamycin), Mefenide acetate (sulfamylon),
Bleomycin, Disulfiram, Cis-Plantinum)
Treatment Plan: Pressure : …….….. ATA
Duration : ………… min
Frequency: ❑ OD ❑ BID ❑ TID ❑ Other…………………………………..………….…………………
Planned Total treatment time: …………………. times
*Remark: ………………………………………………………………………………………………………………………..
FM-HBO-010-00
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