Applicable to Surgery, IM, OB

For Pedia, ask your resident

DO NOT WRITE text in RED (comments only)

Transfer out order (from Recovery Room)

Date/Time S-O-A-P ORDERS
4/1/13 T-36.2 P-80 RR-18 BP-100/70  May transfer out patient back to room
930 AM (-) Headache (-) vomiting  Discontinue O2 and pulse oximeter
For spinal anesthesia:  Monitor vital signs q hourly until stable
(+) able to flex both knees
 MIO q hour and record; refer urine output less than
30 cc/hr
 Watch out for any untoward s/sx such as
hypotension and bleeding
 Refer accordingly
 Thank you.
signature
Dr. Resident(Surname)/JI(Surname)

Cardiopulmonary Status (CP Status) for blood transfusion

Date/Time S-O-A-P ORDERS
4/2/13 T-36.6 P-80 RR-18 BP-110/70  CP status assessed
7 PM Clear breath sounds, symmetrical  May transfuse available unit of PRBC of patient’s
chest expansion; (-) dyspnea blood type after crossmatching to run for 4 hours
(-) DOB; adynamic precordium Initially run 15-25 drops/min and titrate if without (
regular rate and rhythm (
BT reactions
optional

 Mainline to KVO while on BT

 Vital signs q15 minutes for the 1st hour then q hourly
if without BT reactions
 Watch out for BT reactions such as fever,
tachycardia, tachypnea, rashes, pulmonary
congestion
 Refer accordingly
 Thank you
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Dr. Resident(Surname)/JI(Surname)

Skin Test Interpretation

Date/Time S-O-A-P ORDERS
4/3/13  NST to Cefuroxime (Zegen)
Time skin test was read signature
340 PM Dr. Resident(Surname)/JI(Surname)
*NST – negative skin test
 IV Follow up
Date/Time S-O-A-P ORDERS
1. Note that drops/min (gtts/min), microdrops/min (ugtts/min), and cc/hour may differ.
Take note!
2. Some patients have alternating IV fluids e.g. DsLR then D5NM then D5LR again.
3. Ask the nurse in charge when you’re not sure.
4. Pedia interns: Pediatric patients are very prone to fluid overload if you order the wrong
rate. Be careful.
4/4/13  IVF to ff: D5LR 1L x 125cc/hr
signature
4 PM Dr. Resident(Surname)/JI(Surname)

STAT doses as ordered by your resident

Date/Time S-O-A-P ORDERS
4/5/13 T-38.5 °C  Paracetamol 300 mg IV now. signature
4 PM Dr. Resident(Surname)/JI(Surname)

Surgery Admitting Notes

Date/Time S-O-A-P ORDERS
4/6/13 T  Please admit patient to room of choice under the
P service of Dr. (Consultant)
R  TPR q4H and record
BP  Diet: NPO temporarily
Pertinent PE

cc: RLQ pain  IVF: D5LR 1L x 125cc/hour

PPE: (+) Direct tenderness RLQ  Labs: CBC
(+) Loss of appetite BT *BT – Blood type
S. Na, K
Urinalysis
 Meds: Ranitidine 50mg IV now then q8H
 SO: vital signs q4H and record
MIO q shift and record
Watch out for untoward s/sx
Refer accordingly
Will inform AP.
Thank you. signature
Dr. Resident(Surname)/JI(Surname)