PLACE LABEL HERE

CRITICAL CARETRANSFER ORDERS

(Decrease Level of Care)

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

Transfer Service To: ______(critical care sign off)

Transfer Diagnosis(es): ______

Physician Consult: ______ Notified

  1.  Change Patient Status to: Admit to Inpatient (check if patient currently in observation status)
  2. Level of Care:  Intermediate Care Acute Care
  3. Transfer patient to: ______(Department Preference)
  4. Telemetry: If patient Medical/Surgical, must complete form # 36084
  5. Transfer admitting physician to Dr:______; and remove intensivist from patient list
  6. If hospitalist is the attending notify hospitalist “on call for admissions” to notify of room placement

Notify attending Physician of room placement (Non-Hospitalist attending physician)

  1. Prior to Transfer FROM CRITICAL CARE Department

Discontinue Arterial Blood Pressure, Central Venous Pressure, and/or Intra Abdominal Pressure Monitoring

IV Access:

Discontinue PA Catheter

Discontinue PICC line, Central Venus Catheter and Insert INT

orMaintain PICC or CVC for IV access

 Discontinue dialysis catheter

Foley catheter: Discontinue Foley now or  Maintain Foley: (reason) ______

  1. AM Diagnostics:

 CBC  CMP Chem 7 Magnesium level Phosphorus level ABG

 Portable CXR Reason: ______ CXR PA & Lateral Reason: ______

 EKG 12 lead Reason: ______Read by: ______

  1. Patient with actual or suspected sleep apnea: Implement Sleep Apnea Orders (form # 21266)
  2. Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)
  3. Vital signs per unit routine or  q 4 hrs

 Neuro checks q ______hrs

  1. I&O:

Intake and output per unit routine or q ____ hrs

Call physician if urine output is < ____ ml in ____ hrs or no urine output in ____ hrs

  1. Daily Weights

Copy to pharmacyOrder writer’s initials ______

*3-1371* FORM 3-1371 REV. 02/2016 Page 1 of 2

PLACE LABEL HERE

CRITICAL CARETRANSFER ORDERS

(Decrease Level of Care)

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

  1. Glycemic control
  2. Blood glucose checks AC & HS or every 6 hours
  3. For blood glucose ______use the following: BG-100/______#units Humalog SQ
  4. Surgical Dressing Change Instructions: ______
  1. Wound Care Instructions: ______
  2. Drain Care Instructions: ______
  3. Diet:  NPO  Regular  Clear liquid  Full liquid  Cardiac  Renal  Diabetic ______calorie
  4. Rehab:

PT Eval & Treat(reason) ______

 OT Eval & Treat (reason) ______

 Speech Consult (reason) ______

MEDICATION ORDERS:

  1. VTE prophylaxis: Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058)

 Low Risk: No pharmacologic or mechanical prophylaxis. Ambulate 3 times daily.

Therapeutic on current VTE prophylaxis

Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg or age > 75)

orLovenox (enoxaparin) 40 mg SQ daily at 1700 (30 mg if CrCl < 30 ml/min)

Mechanical devices: Sequential Compression Devices

Providers: Medication Reconciliation Must Be CompletedUpon Transfer. See Medication Reorder Form.

ADDITIONAL ORDERS:

______

______

______

______

______

______

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-1371 REV. 02/2016 Page 2 of 2