ITEMS WITH BOXES/PARENTHASES MUST BE CHECKED TO BE ORDERED.

Orders that have been changed (additions, deletions, or strike outs) must be initialed by the ordering MD for the order to be valid.
PHYSICIAN’S ORDER INTRAVENOUS FLUID and MEDICATION ORDERS
(EXCLUDING IV Fluids and MEDICATIONS)
Routine Postpartum Orders ALLERGY:

DATE: _________________ TIME: ______________

IVF and MEDICATION ORDERS ONLY

( ) VS and fundal checks every 15 minutes x 4;
then every 30 minutes x 2; then every 4 hours if ( ) Ibuprofen (Motrin) 600 mg PO every 6 hours PRN for
stable. pain/uterine cramping (pain scale 1-5 or ___________)
( ) Intrathecal Duramorph was given at _____________. ( ) Tylenol 650 mg PO every 4 hours PRN pain, give if
Monitor and record O2 Sat and Respirations Rate patient is allergic to Motrin (pain scale 1-5 or ________)
every 1 hour x 12 hours, then every 2 hours x 12 * maximum of four (4) grams acetaminophen in 24 hours
hours for 24 hours total.
( ) Regular diet. ( ) Tylenol #3 PO 2 tablets every 4 hours PRN

IVF and MEDICATION ORDERS ONLY

pain (pain scale 6-10 or __________________)
( ) Hemoglobin and Hematocrit if estimated (Hold x 24 hours if Duramorph given).
blood loss is over 500 ml or hemoglobin is * maximum of four (4) grams acetaminophen in 24 hours.
below 12 gms.
( ) CBC in am. ( ) Continue present IV fluids at the rate previously ordered
then follow with Ringer’s Lactate 1 liter with 20 units
( ) If baby is Rh positive and mother is Rh negative, do of Pitocin added at 125 ml per hour. Discontinue IV
fetomaternal blood screen (draw at same time as thereafter.
postpartum lab draw).
( ) Measles, Mumps, and Rubella vaccine subcutaneously
( ) Icepacks to perineum x 24 hours if sutures.
IVF and MEDICATION ORDERS ONLY

if rubella non-immune or equivocal.

( ) Sitzbath TID PRN episiotomy.
( ) Ferrous Sulfate 325 mg one (1) PO TID.
( ) Cath if bladder distended and patient report
inability to void. ( ) Prenatal vitamin 1 tablet PO daily.
( ) Insert foley cath if third cath required.
( ) Anusol HC Cream topical QID PRN for hemorrhoids.
( ) Up ad lib
( ) Hygiene activity; may shower ( ) Rhogam 300 mcg IM if mother is RH negative and baby
is RH positive.
IVF and MEDICATION ORDERS ONLY

Other:
( ) Rooming-in. Other:
( ) Breastfeeding. ( ) ____________________________________________

( ) Smoking Cessation Counseling ( ) ____________________________________________

( ) May have outside food
Routine Order: ___________________________________
( ) Children may visit during visiting time
( ) Notify provider for temperature elevation 102°F, or Nurse: _________________________________________
greater than 100.4°F on two Occasions 4 hours apart.
PHYSICIAN/CNM:_______________________________
( ) Social Service consult if indicated
(Reason): __________________________________ Date: _______________ Time: _____________

 Summary/Blanket orders are unacceptable. DO NOT USE:

PATIENT ID LABEL
 Medication orders must be complete. U MS
 PRN medication orders must include an indication. IU MSO4
 Write legibly. Q.D. MgSO4
 Rewrite orders upon transfer and/or post-operatively. Q.O.D. Trailing zero
 Date, time, and sign verbal & telephone orders within 48 hours. Lack of leading zero

Physician’s Order Form - Routine Postpartum Orders

Guam Memorial Hospital Authority
FORM REVISED: 11/2012 APPROVED DATE: NM 04/17/15; OB/GYN 04/28/15; ANESTHESIA 04//28/15; P&T 04/24/15; MEC 04/29/15; HIMC 04/30/15
GMHA FORM # 04902 STOCK # 9904902