CORAZON LOCSIN MONTELIBANO MEMORIAL REGIONAL HOSPITAL

Lacson – Burgos Streets, Bacolod City

DOCTOR’S ORDER/PROGRESS NOTES

NURSES’ COMPLIANCE SHEET
(Authenticate all Orders)

Name of Patient VILLAR, CELSA Hospital No.

Address Ward / Room Ortho – Floor 2
Age 76 Sex Female Admission Date 13 April 2024
C- CARRIED A-ADMINISTERED R-REQUEST MADE E-ENDORSED D-DISCONTINUED
Date TIME
Progress Notes Doctor’s Order C A R E D
Time SIGNATURE
13 Please admit patient to ORTHO WARD at FLOOR 2 under
Diagnosis -
April Fracture Closed Complete Displaced Femoral Neck the adult service of Doctors Panisa / Albelda / Castilo
2024 Right secondary to Fall Secure signed consent of care
9:30 NOI - Fall from standing height
Monitor vital signs q shift
am DOI – Diet – As tolerated, to include 1 boiled egg per meal
TOI – Position patient on high back rest during feeding
POI – Sagay City
IVF – 1L PNSS to run 120 ml per hour x 3 cycles
HISTORY – Diagnostics –
 CBC, Blood typing, PT, PTT
 BUN, Crea, Na, K
 Hba1c, Serum Albumin
 ESR, CRP, FBS, Lipid profile
 12 Lead ECG c/o Heart Station
 Xray – CXR PA, Pelvis PA, Hip crosstable lateral
PMH - right, Thigh AP/L : without supervision
 2D Echo – for scheduling
 CBG – TID premeals and record
Medications –
 Enoxaparin 0.4 IU via subcutaneous OD
 Omeprazole 40mg IV OD
On PE -  Paracetamol 500mg tablet PRN for Fever
 Ketorolac 30mg IV PRN for pain
 Ascorbic Acid 500mg tablet OD
 Ferrous Sulfate tablet OD
 N-Acetylcystein 600mg tablet mix in 1 glass
water 2x daily
Special Orders -
 OR plan – Partial Hip Arthroplasty Right
 Secure consent for operative plan
Plan -
 Secure 1 unit PRBC once at ward
For admission  Refer patient to rehab for general body
For application of skeletal traction conditioning and exercises for DVT prophylaxis
OR plan : Partial Hip Arthroplasty Right  Refer patient to IM for CP clearance once all
labs in
 Strict bed turning every 2 hours once at ward
 Egg crate mattress foam at bed
 Soft paddings on bony prominences
 Refer accordingly

_________________, MD
Admitting Resident

Doctor’s Orders Form

CLMMRH-MRS.F.032
Issued: 2/5/14
Issue .No. 001
 CORAZON LOCSIN MONTELIBANO MEMORIAL REGIONAL HOSPITAL
Lacson – Burgos Streets, Bacolod City

DOCTOR’S ORDER/PROGRESS NOTES

NURSES’ COMPLIANCE SHEET
(Authenticate all Orders)

Doctor’s Orders Form

CLMMRH-MRS.F.032
Issued: 2/5/14
Issue .No. 001
 CORAZON LOCSIN MONTELIBANO MEMORIAL REGIONAL HOSPITAL
Lacson – Burgos Streets, Bacolod City

DOCTOR’S ORDER/PROGRESS NOTES

NURSES’ COMPLIANCE SHEET
(Authenticate all Orders)

Doctor’s Orders Form

CLMMRH-MRS.F.032
Issued: 2/5/14
Issue .No. 001