PHYSICIAN ADMISSION ORDERS Southtowne Living Center 360 W 28th Ave Eugene OR 97405 Fax: (541) 342-8130 Phone: (541) 683-3618 Resident Name: ______________________________ Date of Birth: _____________ Sex: M or F ORDERS This resident is not in need of 24-hour Skilled Nursing Care RECOMMENDED DIET: Residents living in this community are provided foods consistent with their physician ordered diet, though each resident has the right to make their own diet choices. _____Regular Diet
_____Controlled Carbohydrates
Texture: _____ Regular _____Pureed _____ Mechanical Soft _____ Cut Up _____Finger Foods
Annual Influenza Vaccination Recommended? _____Yes Date of Last Influenza Vaccine: _____________________
_____No
May crush all 'crushable' medications if needed, and may place in carrier of choice: _____Yes _____No
MEDICATION ADMINISTRATION ____ Resident requires total assistance with medication administration. Staff will centrally store medications. ____ Resident can determine and communicate the need for PRN medications? ____Yes ____No Notify Physician of refusal of medications: _____Daily _____Weekly _____Monthly _____Never
Allergies:_______________________________________________________________________ _______________________________________________________________________________
_________________________________________________________ Physician Signature Ageia Health Services
______________________________ Date 1 Standing Physicians Orders Revised 9-2013
Date:
Physician Name:
Physician Fax#
Resident Name:
ORDERS Diagnosis: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
Current Medications: (Please complete all areas requested for each medication) Medication Name
Dose
Instructions
Diagnosis/Condition
Standing Orders to include the following: Discontinue PRN medications not used in 60 days. Substitute generic medications unless otherwise indicated. Physician Orders in effect for 180 days unless otherwise indicated Hold medication until new dose arrives, and/or continue current dose until new medication arrives Physician signature on Page 3 is effective for all 3 pages. Please check the appropriate boxes you would like included in your orders. DNR
CPR
(Please attach the completed directive.)
_________________________________________________________ Physician Signature Ageia Health Services
______________________________ Date 2 Standing Physicians Orders Revised 9-2013
Date:
Physician Name:
Physician Fax #:
Resident Name:
PRN’s, Standing Orders and Protocols: Indicate below, each item to be included in your patients’ Standing Orders Acetaminophen (325 mg tablets): 2 tablets by mouth every 4 hours for headache, mild to moderate joint or muscular discomfort or fever greater than 99.9 degrees Fahrenheit as needed. Milk of Magnesia (MOM) 30 ml: By mouth daily as needed for complaints of constipation. Milk of Magnesia (MOM) 15 ml: By mouth daily as needed for complaints of stomach acidity. Calmoseptine:
Apply topically as needed for redness to peri and buttock area after cleansing skin. LN must be notified when Calmoseptine has been initially applied.
Skin Tear Treatment:
Gently wash with soap and water or wound cleaner, pat dry with gauze 4x4, gently close skin flap (if skin flap remains) using a cotton swab, steri-strip flap to intact skin, cover with non-adherent dressing and secure with rolled gauze. Do not tape dressing to skin. Notify LN immediately. Remove dressing after 24 hours; allow steri-strips to fall off. Monitor daily until resolved.
Obtain a urine specimen for UA C&S as indicated if resident has S/Sx of UTI:
Signs and symptoms are as follows: frequency, complaints of burning, urgency, pain upon urination, temperature over 99.9 degrees Fahrenheit, change of consciousness and/or increased confusion.
*If not verbally able to indicate constipation, indicators will be established per assessment by the LN.
_________________________________________________________ Physician Signature
______________________________ Date 3
Ageia Health Services
Standing Physicians Orders
Revised 9-2013
