Unit Specific Orders and Forms
Sutter Medical Center, Sacramento

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Display All Units ------ 3Center & 5 Center SMH4C & 4E SMH4E & NOU SGH4North Orthopedics SGH4So & 5So SGH4W & BMT SGHED SMH & SGHHeart CathHospitalistsICU's & CVIU SGH & SMHIV TherapyL & D, ATU, 2C, Maternal Newborn SMHNursing Administration SMH & SGHPediatrics & PICU SMHRadiology SMH & SGHSpecial Care Nursery/NICUSurgery SMH & SGHPer Diem/PAASocial WorkDialysisSOMT

3Center & 5 Center SMH

Preprinted Orders Number Title Specialty 00167 Pneumonia Orders - Adult Pulmonary 00419 Comfort Care : H&P Progress Notes and Disch. Sum.; Orders Non-Viable Live Birth Obstetrics 00583 Post-Anesthesia Treatment and Drug Orders (Phase I) Anesthesia 00831 Stroke Orders Acute, pgs. 1-2 Stroke 01084 GYN/Urogynecology (Post Op) Gyn 01118 TPN Order Form Adult TPN 01442 Pain Management Orders Acute Anesthesia 01732 Heart Catherization Pre Op Orders Heart Cath 02134 Heparin Drip Protocol Maintenance Orders Protocols 02457 Anesthesia Pre-Operative Anesthesia 05030 Pulmonary Admission Orders - Interactive PMA 05030 - 01 PMA/ICU - ICU Admission Orders PMA 05030 - 02 PMA/ICU Intensive Insulin Treatment Protocol PMA 05030 - 04 PMA/ICU Acute Respiratory Failure Orders PMA 05030 - 05 PMA/ICU ARDS Orders PMA 05030 - 07 PMA/ICU Acute Cardiac Orders PMA 05030 - 08 PMA/ICU Hypertension Control Orders IV PMA 05030 - 09 PMA/SVT Rapid Atrial Fib and Tachycardia, Related to Acute Coronary Syndrome PMA 05030 - 10 PMA/ICU GI Bleed -Anemia Orders PMA 05030 - 11 PMA/ICU Alchohol Withdrawal Orders PMA 09345 Restraint: Physician Order Hard Copy Only 09348 SNF Transfer Summary Hard Copy Only 09572 Induction of Labor Mid-Trimester Obstetrics 09850 Emergency Procedures for Monitored and Non-Monitored Areas Hard Copy Only 09912 Heart Failure Admission Orders Cardiac 20018 D & C Orders, Pre Op Obstetrics 20021 tPA - Intravenous Thrombolytic Therapy for Acute Stroke Stroke 20037 Transfer - Acute Inpatient Summary Admission 20053 Comfort Care Orders Medical 20662 PICC Protocol Orders - Adult & Pediatric Protocols 20663 Chest Pain Rule Out Acute Coronary Syndrome Cardiac 20718 Stroke Discharge Orders/Instructions and Prescription Stroke 20759 Non Ambulance Order Form Hard Copy Only 20760 Ambulance Order Form Hard Copy Only 20792 Smoking Cessation Protocol Orders Protocols 21034 Heart Failure Discharge Orders Cardiac 21064 Acute Coronary Syndrome/Acute MI Admission Orders pp. 1-2 Cardiac 21065 Acute Coronary Syndrome Discharge Summary pp. 1-2 Cardiac 21078 Insulin Drip Non-Pregnant Adult (Physician Order) Diabetes 21092 Stroke Post Alteplase (t-PA) Acute Ischemic Orders pp. 1-2 Stroke 21211 Wound and Skin Care Protocol Protocols 21260 Gynecology/Urogynecology Patients Standard Admission Orders Gyn 21324 Admission Orders- Adult Non -Surgical Admission 21390 Pneumococcal/Influenza Immunization Protocol (Please see Hospital Forms) Immunization 21395 Medication Reconciliation and Order Form Hard Copy Only 21531 Admission orders - Dr Morkoc Admission 21584 Central Venous Catheter (Non-PICC) Post Insertion Protocol Orders Protocols 21687 Pressure Ulcer Supplemental Orders Medical 21709 Peripheral Vascular Orders Post Op IPOC Acute Coronary Syndrome IPOC Acute Ischemic Stroke IPOC CVA, Cardiovascular Accident IPOC Heart Failure IPOC Pneumonia PEP Acute Coronary Syndrome PEP Heart Failure PEP Pneumonia PEP Stroke Hospital Forms Number Title Category 3C SBAR Report Form Worksheets Smoking Cessation Patient Information Patient Education 00067 Autopsy: Authorization for.. Print 2 Copies Consents 00075 Fetal /Neonatal Plan of Care MD Documentation, Nursing Documentation 00152 Death: Record of Death & Disposition Form in Central Services 00215 Continuing Education Duty Time Request Hospital 00235 Paul Gann Transfusion Information Form Print 2 Copies Consents 00285 Physician Progress Notes MD Documentation 00338 Discharge Instructions - Generic Nursing Print 2 Copies Discharge Instructions 00395 Consent for Vaccine Administration Print 2 Copies Consents 00431 Refusal of Treatment, Procedure and/or Safety Device Hospital 00511 Patient Profile Inpatient Adult Nursing Documentation 00576 MAR - Medication Administration Record MAR's 00650 Anesthesia Evaluation MD Documentation 00736 Authorization for Restriction on Release of Personal Health Information (No info) Hospital 00832 Photo Consent- Adult; Consent to Photograph, Filming, Videotaping, or use of Recording Devices Print 2 Copies Consents 00966 Consultation Record MD Documentation 01052 Lost/Damaged Property Hospital 01070 Surgical Checklist Nursing Documentation 06157 Medication Event & Near Miss Evaluation Hospital 09268 Sedation Record, Patient Nursing Documentation 09513 Fire Event Evaluation Hospital 09545 Short Form Operative and Invasive Procedures MD Documentation 09755 Employment and Orientation Notification Worksheet Worksheets 20022 PCA Intravenous Patient-Controlled Analgesia Patient Education 20143 3C Assignment Sheet and Break Log Worksheets 20283 Resuscitation Review Nursing Documentation 20301 Crash Cart Checklist Nursing Documentation 20392 Managing Your Pain: what you need to know Patient Education 20433 Staffing Office Info to Fax Worksheet Worksheets 20675 MD Progress Notes (formatted) MD Documentation 20797 5C Assignment Sheet and Break Log Worksheets 21010 Heart Care At a Glance, Heart Failure Discharge Instructions Print 2 Copies Discharge Instructions 21022 3C / 5C Inter-Staff Communication/ I & O's Worksheets 21224 Dysphagia Screening for Stroke Patients Nursing Documentation 21390 Pneumococcal/Influenza Immunization Protocol Nursing Documentation 21414 Pyxis User Request Hospital 21618 Ticket to Ride Worksheet Worksheets 21672 MAR - Insulin Regular - Mild MAR's 21673 MAR - Insulin Regular - Moderate MAR's 21674 MAR - Insulin Regular - Aggressive MAR's 21675 MAR - Insulin Lispro - Mild MAR's 21676 MAR - Insulin Lispro - Moderate MAR's 21677 MAR - Insulin Lispro - Aggressive MAR's 21723 MAR - Bowel Care - Renal MAR's 21724 MAR - Bowel Care - Routine MAR's 21725 MAR - Potassium and Magnesium Replacement Protocol MAR's 21728 MAR - Adult Admission Orders (Non-Surgical) 21324 MAR's 21728 MAR - Adult Admission Orders (Non-Surgical) 21324 MAR's 21729 MAR - Chest Pain - Rule out Acute Coronary Syndrome 20663 MAR's References Number Title   Tips for Helping Children Cope with a Loved One's Serious Illness

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4C & 4E SMH

Preprinted Orders Number Title Specialty 00167 Pneumonia Orders - Adult Pulmonary 00255 Heart Transplant Telemetry Orders Adult Cardiac 00264 Heart Transplant Steroid Taper Orders Adult Heart Transplant 00269 Heart Transplant Pre Op Orders Adult Heart Transplant 00303 Renal with Pancreas or Solitary Pancreas Transplant- Adult Pre Op Orders Renal Transplant 00304 Renal with Pancreas or Solitary Pancreas Transplant - Adult Post Op Orders Renal Transplant 00312 - A Renal Transplant (only) Post Op Orders- Adult Cadaveric Donor or Living Donor with Less than 3 Antigen Match Renal Transplant 00312 - B Renal Transplant Post Op Orders, Adult Living Donor with 3-5 Antigen Match Renal Renal Transplant 00312 - C Renal Transplant Post Op Orders, Adult Living Donor with Identical HLA Match Renal Renal Transplant 00364 Heart Transplant Pre-Endomyocardial Biopsy Orders Heart Transplant 00831 Stroke Orders Acute, pgs. 1-2 Stroke 01118 TPN Order Form Adult TPN 01189 Percutaneous Coronary Intervention (Orders for) Heart Cath 01442 Pain Management Orders Acute Anesthesia 01732 Heart Catherization Pre Op Orders Heart Cath 02134 Heparin Drip Protocol Maintenance Orders Protocols 09348 SNF Transfer Summary Hard Copy Only 09850 Emergency Procedures for Monitored and Non-Monitored Areas Hard Copy Only 09912 Heart Failure Admission Orders Cardiac 20037 Transfer - Acute Inpatient Summary Admission 20053 Comfort Care Orders Medical 20662 PICC Protocol Orders - Adult & Pediatric Protocols 20663 Chest Pain Rule Out Acute Coronary Syndrome Cardiac 20718 Stroke Discharge Orders/Instructions and Prescription Stroke 20759 Non Ambulance Order Form Hard Copy Only 20760 Ambulance Order Form Hard Copy Only 20792 Smoking Cessation Protocol Orders Protocols 21034 Heart Failure Discharge Orders Cardiac 21048 Adult Ketoacidosis & Hyperosmolar Non Ketotic Syndrome Diabetes 21064 Acute Coronary Syndrome/Acute MI Admission Orders pp. 1-2 Cardiac 21065 Acute Coronary Syndrome Discharge Summary pp. 1-2 Cardiac 21078 Insulin Drip Non-Pregnant Adult (Physician Order) Diabetes 21092 Stroke Post Alteplase (t-PA) Acute Ischemic Orders pp. 1-2 Stroke 21182 Renal Transplant (only)-Adult Pre Op Orders Renal Transplant 21186 Renal Transplant (Living Donor) Nephrectomy Post Op Renal Transplant 21187 Atrial Fibrillation Orders New Onset Post Op Dr. Arthur Cardiac 21211 Wound and Skin Care Protocol Protocols 21324 Admission Orders- Adult Non -Surgical Admission 21390 Pneumococcal/Influenza Immunization Protocol (Please see Hospital Forms) Immunization 21395 Medication Reconciliation and Order Form Hard Copy Only 21531 Admission orders - Dr Morkoc Admission 21584 Central Venous Catheter (Non-PICC) Post Insertion Protocol Orders Protocols 21687 Pressure Ulcer Supplemental Orders Medical IPOC Acute Coronary Syndrome IPOC Acute Ischemic Stroke IPOC CVA, Cardiovascular Accident IPOC Heart Failure IPOC Pneumonia PEP Acute Coronary Syndrome PEP Heart Failure PEP Pneumonia PEP Stroke Hospital Forms Number Title Category Smoking Cessation Patient Information Patient Education 00034 EKG Rhythm Strips Nursing Documentation 00067 Autopsy: Authorization for.. Print 2 Copies Consents 00152 Death: Record of Death & Disposition Form in Central Services 00215 Continuing Education Duty Time Request Hospital 00235 Paul Gann Transfusion Information Form Print 2 Copies Consents 00285 Physician Progress Notes MD Documentation 00338 Discharge Instructions - Generic Nursing Print 2 Copies Discharge Instructions 00395 Consent for Vaccine Administration Print 2 Copies Consents 00431 Refusal of Treatment, Procedure and/or Safety Device Hospital 00511 Patient Profile Inpatient Adult Nursing Documentation 00576 MAR - Medication Administration Record MAR's 00736 Authorization for Restriction on Release of Personal Health Information (No info) Hospital 00749 Discharge Instructions for Post Heart Catheterization/Angioplasty/Stent Care Print 2 Copies Discharge Instructions 00832 Photo Consent- Adult; Consent to Photograph, Filming, Videotaping, or use of Recording Devices Print 2 Copies Consents 00966 Consultation Record MD Documentation 01052 Lost/Damaged Property Hospital 01070 Surgical Checklist Nursing Documentation 06157 Medication Event & Near Miss Evaluation Hospital 09268 Sedation Record, Patient Nursing Documentation 09513 Fire Event Evaluation Hospital 09545 Short Form Operative and Invasive Procedures MD Documentation 09755 Employment and Orientation Notification Worksheet Worksheets 20022 PCA Intravenous Patient-Controlled Analgesia Patient Education 20283 Resuscitation Review Nursing Documentation 20301 Crash Cart Checklist Nursing Documentation 20392 Managing Your Pain: what you need to know Patient Education 20675 MD Progress Notes (formatted) MD Documentation 21010 Heart Care At a Glance, Heart Failure Discharge Instructions Print 2 Copies Discharge Instructions 21027 Orthostatic Blood pressure Nursing Documentation 21224 Dysphagia Screening for Stroke Patients Nursing Documentation 21366 Sirolimus Flowsheet Worksheets 21367 Tacrolimus Flow Sheet Worksheets 21368 Cyclosporine Flow Worksheet Worksheets 21390 Pneumococcal/Influenza Immunization Protocol Nursing Documentation 21414 Pyxis User Request Hospital 21424 Pacemaker Homecare Inst. Sacramento - Heart and Vascular Med Association Print 2 Copies Discharge Instructions 21425 Pacemaker/ ICD Homecare Inst. Sobkowicz/Berte Print 2 Copies Discharge Instructions 21427 Pacemaker / ICD Homecare Inst. Wolf Print 2 Copies Discharge Instructions 21431 Monitor Tech Patient Report Worksheets 21454 Pacemaker/ICD Homecare Instructions- Dr Kim Print 2 Copies Discharge Instructions 21618 Ticket to Ride Worksheet Worksheets 21634 ICD Discharge Instructions - Dr. Stark Print 2 Copies Discharge Instructions 21642 Pacemaker / ICD Homecare Inst.- Generic Print 2 Copies Discharge Instructions 21672 MAR - Insulin Regular - Mild MAR's 21673 MAR - Insulin Regular - Moderate MAR's 21674 MAR - Insulin Regular - Aggressive MAR's 21675 MAR - Insulin Lispro - Mild MAR's 21676 MAR - Insulin Lispro - Moderate MAR's 21677 MAR - Insulin Lispro - Aggressive MAR's 21696 Daily Progress for CV Surgery Patient Education 21723 MAR - Bowel Care - Renal MAR's 21724 MAR - Bowel Care - Routine MAR's 21725 MAR - Potassium and Magnesium Replacement Protocol MAR's 21728 MAR - Adult Admission Orders (Non-Surgical) 21324 MAR's 21728 MAR - Adult Admission Orders (Non-Surgical) 21324 MAR's 21729 MAR - Chest Pain - Rule out Acute Coronary Syndrome 20663 MAR's References Number Title   Tips for Helping Children Cope with a Loved One's Serious Illness

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4E & NOU SGH

Preprinted Orders Number Title Specialty 00167 Pneumonia Orders - Adult Pulmonary 00831 Stroke Orders Acute, pgs. 1-2 Stroke 09912 Heart Failure Admission Orders Cardiac 20718 Stroke Discharge Orders/Instructions and Prescription Stroke 20792 Smoking Cessation Protocol Orders Protocols 21034 Heart Failure Discharge Orders Cardiac 21052 Epilepsy Monitoring Unit - Post Op Phase II Craniotomy for Grid, Strip & Electrode Placement pp. 1-2 Neuro 21055 Craniotomy Post Op Dr's. Cobb, Robbins, Yen pp. 1-2 Neuro 21064 Acute Coronary Syndrome/Acute MI Admission Orders pp. 1-2 Cardiac 21065 Acute Coronary Syndrome Discharge Summary pp. 1-2 Cardiac 21078 Insulin Drip Non-Pregnant Adult (Physician Order) Diabetes 21092 Stroke Post Alteplase (t-PA) Acute Ischemic Orders pp. 1-2 Stroke 21211 Wound and Skin Care Protocol Protocols 21324 Admission Orders- Adult Non -Surgical Admission 21390 Pneumococcal/Influenza Immunization Protocol (Please see Hospital Forms) Immunization 21395 Medication Reconciliation and Order Form Hard Copy Only 21531 Admission orders - Dr Morkoc Admission 21584 Central Venous Catheter (Non-PICC) Post Insertion Protocol Orders Protocols 21632 Subarachnoid Hemorrhage/Aneurysm Admission Orders Stroke 21709 Peripheral Vascular Orders Post Op IPOC Acute Coronary Syndrome IPOC Acute Ischemic Stroke IPOC CVA, Cardiovascular Accident IPOC Heart Failure IPOC Pneumonia PEP Acute Coronary Syndrome PEP Heart Failure PEP Pneumonia PEP Stroke Hospital Forms Number Title Category 4 East Neurology Orientation Worksheets Smoking Cessation Patient Information Patient Education 00034 EKG Rhythm Strips Nursing Documentation 00067 Autopsy: Authorization for.. Print 2 Copies Consents 00152 Death: Record of Death & Disposition Form in Central Services 00215 Continuing Education Duty Time Request Hospital 00235 Paul Gann Transfusion Information Form Print 2 Copies Consents 00285 Physician Progress Notes MD Documentation 00338 Discharge Instructions - Generic Nursing Print 2 Copies Discharge Instructions 00395 Consent for Vaccine Administration Print 2 Copies Consents 00431 Refusal of Treatment, Procedure and/or Safety Device Hospital 00511 Patient Profile Inpatient Adult Nursing Documentation 00576 MAR - Medication Administration Record MAR's 00736 Authorization for Restriction on Release of Personal Health Information (No info) Hospital 00787 Diabetic Record Nursing Documentation 00832 Photo Consent- Adult; Consent to Photograph, Filming, Videotaping, or use of Recording Devices Print 2 Copies Consents 00966 Consultation Record MD Documentation 01052 Lost/Damaged Property Hospital 01070 Surgical Checklist Nursing Documentation 06157 Medication Event & Near Miss Evaluation Hospital 09268 Sedation Record, Patient Nursing Documentation 09513 Fire Event Evaluation Hospital 09545 Short Form Operative and Invasive Procedures MD Documentation 09755 Employment and Orientation Notification Worksheet Worksheets 20022 PCA Intravenous Patient-Controlled Analgesia Patient Education 20283 Resuscitation Review Nursing Documentation 20301 Crash Cart Checklist Nursing Documentation 20392 Managing Your Pain: what you need to know Patient Education 20650 Authorization for Use or Disclosure of Health Information Print 2 Copies Consents 20675 MD Progress Notes (formatted) MD Documentation 20725 Cervical Discectomy Flowsheet Nursing Documentation 20777 EMU Monitor Tech Activity Sheet Worksheets 21224 Dysphagia Screening for Stroke Patients Nursing Documentation 21226 Thoracic or Lumbar Laminectomy/Disectomy Flowsheet Nursing Documentation 21341 Stroke RN Acute Progress Note Nursing Documentation 21390 Pneumococcal/Influenza Immunization Protocol Nursing Documentation 21414 Pyxis User Request Hospital 21431 Monitor Tech Patient Report Worksheets 21618 Ticket to Ride Worksheet Worksheets 21672 MAR - Insulin Regular - Mild MAR's 21673 MAR - Insulin Regular - Moderate MAR's 21674 MAR - Insulin Regular - Aggressive MAR's 21675 MAR - Insulin Lispro - Mild MAR's 21676 MAR - Insulin Lispro - Moderate MAR's 21677 MAR - Insulin Lispro - Aggressive MAR's 21723 MAR - Bowel Care - Renal MAR's 21724 MAR - Bowel Care - Routine MAR's 21725 MAR - Potassium and Magnesium Replacement Protocol MAR's 21728 MAR - Adult Admission Orders (Non-Surgical) 21324 MAR's 21728 MAR - Adult Admission Orders (Non-Surgical) 21324 MAR's 21729 MAR - Chest Pain - Rule out Acute Coronary Syndrome 20663 MAR's References Number Title   Tips for Helping Children Cope with a Loved One's Serious Illness

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4North Orthopedics SGH

Preprinted Orders Number Title Specialty 00167 Pneumonia Orders - Adult Pulmonary 00583 Post-Anesthesia Treatment and Drug Orders (Phase I) Anesthesia 00831 Stroke Orders Acute, pgs. 1-2 Stroke 01118 TPN Order Form Adult TPN 01442 Pain Management Orders Acute Anesthesia 02134 Heparin Drip Protocol Maintenance Orders Protocols 02766 ACL reconstruction without Patellar Tendon Bone Graft - Post Op Post Op 02767 Shoulder Replacement/Shoulder Repair Post OP Orders Post Op 02768 Hip Total Hip Replacement (Post Op) Post Op 02769 Knee Total Knee Replacement (Post Op) Post Op 09345 Restraint: Physician Order Hard Copy Only 09366 Lumbar Discectomy/Laminectomy Post Op 09760 Chest Pain ACS/AMI Orders (Emergency) Chest Pain 09850 Emergency Procedures for Monitored and Non-Monitored Areas Hard Copy Only 09912 Heart Failure Admission Orders Cardiac 20021 tPA - Intravenous Thrombolytic Therapy for Acute Stroke Stroke 20037 Transfer - Acute Inpatient Summary Admission