Lhopic103

PHYSICIAN ORDERS
OUTPATIENT INFUSION CENTER
PATIENT: __________________________________________________________ DOB: ________________
EMERGENCY PROTOCOL FOR ACUTE REACTION
Please Sign Below
Mild/Moderate
diaphoresis, headache, dizziness, nausea, urticaria, hypo/hypertension (≥20 points with rigors, hyperemia, chest discomfort, SBP), chest discomfort, dyspnea, elevated significant shortness of breath., stridor Ø Infuse NS @ 500mL/hr PRN for SBP <80 Ø Give O2 via NC@4 L/min for Sat. <92 £ Hydrocortisone 100mg IVP x1£ Demerol 25 mg IV PRN rigors, repeat x1 in 15 minutes if rigors persist and BP is • Emergency Room Admittance if required Print Name of Referring Clinician: ____________________________________________________________ Title: MD / DO / NP / PA Clinician Office Phone Number: _____________________________________ Fax: _____________________________________ Clinician’s Signature: ________________________________________________ Date: _______________ Time: _______________
Outpatient Infusion Center
100 East 77th Street, New York, NY 10075, 3rd Floor
Tel: (212) 434-2730 Fax: (212) 434-2939
OPIC BLOOD TRANSFUSION
APPOINTMENT
ORDER FORM
________________ _____________ at _____________ PATIENT NAME: ________________________________________________________________ Date of Birth: ____________________ DIAGNOSES: _________________________________________________________________________________________________ REASON FOR TRANSFUSION: ___________________________________________________________________________________ DATE OF TRANSFUSION: ___________________________________ HAS THE PATIENT EVER BEEN ADMITTED TO LENOX HILL HOSPITAL? _______________________________________________ HAS THE PATIENT EVER BEEN TRANSFUSED BEFORE £ YES £ NO WHERE? _____________________________________ ANY TRANSFUSION REACTIONS? _____________________________________________________________________________ PLEASE TRANSFUSE THE FOLLOWING COMPONENTS:
£ PACKED RED BLOOD CELLS: # OF UNITS: ________ £ IRRADIATED £ WASHED (Needs Blood Bank Director’s Approval 212-434-2510) Infuse each unit over: £ 1 hour £ 1½ hour £ 2 hour £ 3 hour LAST Hgb: __________________ Date: _______________________ £ PLATELETS: # OF UNITS: ________ £ IRRADIATED Infuse each unit over £ 30 min £ 60 min LAST PLATELET COUNT: __________ Date: _______________ (All platelet will be single donor apheresis platelets) £ FRESH FROZEN PLASMA: # UNITS __________ Infuse each unit over: £ 15 min £ 30 min £ 60 min£ CRYOPRECIPITATE: # UNITS __________ Infuse each unit over: £ 15 min £ 30 min £ 60 min £ FACTOR: __________________ (Needs Blood Bank Director’s Approval 212-434-2510) PRE-MEDICATIONS: 30-45 MINUTES PRIOR TO TRANSFUSION
INTERIM & POST:
£ TYLENOL: 650 MG PO X1
£ BENADRYL: 25 MG X1 £ PO £ IV PIGGYBACK £ 50 ML N.S £ 50 ML D5W
£ LASIX ______ MG
£ HYDROCORTISONE: _____ MG X1 £ IV PIGGYBACK £ 50 ML N.S £ 50 ML D5W
£ LASIX: ______ MG X 1
___________________________________________________________________________ £ LASIX ______ MG
____________________________________________________________________________ ____________________________________________________________________________ I CERTIFY THAT I HAVE REQUESTED THE ABOVE BLOOD PRODUCTS AND THAT I HAVE DISCUSSED THE RISKS, BENEFITSAND ALTERNATIVES TO THE TRANSFUSION WITH THE ABOVE NAMED PATIENT. DISCHARGE AFTER TRANSFUSION IF PATIENTMEETS THE DISCHARGE CRITERIA.
Print Name of Referring Clinician: ____________________________________________________________ Title: MD / DO / NP / PA Clinician Office Phone Number:_________________________________ Fax: _______________ Pre-Auth. #: ____________________ Clinician’s Signature: ________________________________________________ Date: _______________ Time: _______________
LHH RN Signature: __________________________________________________ Date: _______________ Time: _______________
Print Name: _______________________________________________________________________________________________
Outpatient Infusion Center
100 East 77th Street, New York, NY 10075, 3rd Floor
Tel: (212) 434-2730 Fax: (212) 434-2939
APPOINTMENT
DATE:
OPIC CLINICIAN’S INITIAL ASSESSMENT
Patient Name: _____________________________________________________ D.O.B.: ____________________ £ Male £ Female Home Phone #: _______________________ Work Phone #: _______________________ Cell Phone #: _______________________ Diagnosis/Chief Complaint: _____________________________________________________________________________________
Allergies: _____________________________________________________________________________________________________ List of Medications: _____________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Date of Physical Assessment: _______________________ VS: HR _______ BP _______ RESP _______ TEMP _______
For Women of childbearing Age: LMP _____________ Pregnant : £ Yes £ No £ NA
NOTE: __________________________________________________ ________________________________________________________ £ Regular Rate and Rhythm without any murmurs, gallops or rubs £ Abnormal: __________________________________________________________________________ £ Breath Sounds without any other adventitious sounds or rubs£ Clear to Auscultation£ Abnormal: __________________________________________________________________________ £ Gait Normal £ No Edema £ No cyanosis/clubbing £ Edema: Location ____________________________________________________________________ Print Name of Referring Clinician: ____________________________________________________________ Title: MD / DO / NP / PA Clinician Office Phone Number: _______________________________________ Fax: _______________________________________ Clinician’s Signature: ________________________________________________ Date: _______________ Time: _______________
LHH RN Signature: __________________________________________________ Date: _______________ Time: _______________
Print Name: _______________________________________________________________________________________________
BLOOD TRANSFUSION
CONSENT FORM
I, hereby authorize Dr. ___________________________________________________ and/or his or her associatesor designees to administer blood transfusions or blood product transfusions as may be needed in the judgment ofthe attending physician or practitioner or his or her designee or assistants during the course of ___________________________________________________________ (Name of patient) hospitalization. The risks,benefits and alternatives to blood transfusions, including withholding transfusions, have been explained to me. Iacknowledge that I have been given an opportunity to ask any questions I have concerning the risks of accepting orrefusing the blood or blood products and my questions have been answered fully and to my satisfaction.
I understand that I can withdraw my consent at any time.
Patient/Healthcare Agent/Guardian/Next-of-kin: ______________________________________________ (Signature) ______________________________________________ ___________________________________________ Relationship: _______________________________________ (If signed by other than patient) _________________________________ _______________________________________ _________________Interpreter (if used) Signature _________________________________ _______________________________________ _________________Witness Signature I hereby certify that the nature, purpose, benefits, risks of, and alternatives to the proposed bloodtransfusion(s) have been explained to the patient. Any and all questions have been answered. I believethat the patient/healthcare agent/guardian/next-of-kin fully understands what has been explained.
_________________________________ _______________________________________ _________________Physician/Practitioner Signature BLOOD TRANSFUSION
REFUSAL FORM
I hereby acknowledge that I refuse and reject transfusions of blood or its derivatives during the course of my treatment at Lenox Hill Hospital. Dr. ________________________________________________ has fully explainedto me the nature and purpose of my course of treatment and has also informed me of the potential need for, benefits,risks, and possible complications of blood transfusions. The risks that may arise from a refusal of transfusions havebeen explained to me. I fully recognize and understand that there are risks to life and health associated with my refusal,including the risk of death, and such risks have been fully explained to me. The physician/practitioner has alsodiscussed with me that there may be available alternatives to transfusions of whole blood. The alternatives and theirbenefits and risks have been fully explained to me, and I refuse to consent to these alternatives as well. I have beengiven the opportunity to ask questions and all my questions have been fully and satisfactorily answered. I herebyrelease Lenox Hill Hospital, its employees, agents, medical staff, medical students, and the attending physicians fromany responsibility whatsoever for unfavorable reactions or any untoward results due to my refusal to consent to theuse of blood, its derivatives, or alternatives. I confirm that I have read and fully understand this Blood TransfusionRefusal form. I have crossed out any words above, which do not pertain to me.
Patient/Healthcare Agent/Guardian/Next-of-kin: ______________________________________________ (Signature) ______________________________________________ ___________________________________________ Relationship: _______________________________________ (If signed by other than patient) _________________________________ _______________________________________ _________________Interpreter (if used) Signature _________________________________ _______________________________________ _________________Witness Signature I hereby certify that the nature, purpose, benefits, risks of, and alternatives to blood/blood producttransfusions and the risks of blood/blood product refusal have been explained to the patient. Any and allquestions have been answered. I believe that the patient/healthcare agent/guardian/next-of-kin fullyunderstands what has been explained _________________________________ _______________________________________ _________________Physician/Practitioner Signature

Source: http://www.lenoxhillhospital.org/uploadedFiles/Content/Departments_and_Services/Departments/Infusion_Center/LHH_OPIC_Blood_Transfusion_Forms.pdf