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    Carrying Out of Doctors Order and Fdar Documentation (Cotabato Regional and Medical Center) Instructions

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    Marielle Chua
    The patient, a 25-year-old pregnant woman, was admitted to the hospital in labor. She was experiencing lumbosacral pain, excessive sweating, and facial grimacing. Upon examination, she was 5 cm dilated. The doctor's orders included admitting the patient, obtaining consent, starting an IV with D5LR and oxytocin, ordering diagnostic tests, monitoring the fetal heart tone every 30 minutes, taking vital signs every 4 hours, and keeping the patient NPO during active labor. The nurse carried out the orders by documenting them on the required forms, including the doctor's order sheet, kardex, IV flow sheet, and vital signs record.

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    Carrying Out of Doctors Order and Fdar Documentation (Cotabato Regional and Medical Center) Instructions

    Uploaded by

    Marielle Chua
    522 views6 pages
    The patient, a 25-year-old pregnant woman, was admitted to the hospital in labor. She was experiencing lumbosacral pain, excessive sweating, and facial grimacing. Upon examination, she was 5 cm dilated. The doctor's orders included admitting the patient, obtaining consent, starting an IV with D5LR and oxytocin, ordering diagnostic tests, monitoring the fetal heart tone every 30 minutes, taking vital signs every 4 hours, and keeping the patient NPO during active labor. The nurse carried out the orders by documenting them on the required forms, including the doctor's order sheet, kardex, IV flow sheet, and vital signs record.

    Original Title

    Doctors Order Crmc

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    The patient, a 25-year-old pregnant woman, was admitted to the hospital in labor. She was experiencing lumbosacral pain, excessive sweating, and facial grimacing. Upon examination, she was 5 cm dilated. The doctor's orders included admitting the patient, obtaining consent, starting an IV with D5LR and oxytocin, ordering diagnostic tests, monitoring the fetal heart tone every 30 minutes, taking vital signs every 4 hours, and keeping the patient NPO during active labor. The nurse carried out the orders by documenting them on the required forms, including the doctor's order sheet, kardex, IV flow sheet, and vital signs record.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    522 views6 pages

    Carrying Out of Doctors Order and Fdar Documentation (Cotabato Regional and Medical Center) Instructions

    Uploaded by

    Marielle Chua
    The patient, a 25-year-old pregnant woman, was admitted to the hospital in labor. She was experiencing lumbosacral pain, excessive sweating, and facial grimacing. Upon examination, she was 5 cm dilated. The doctor's orders included admitting the patient, obtaining consent, starting an IV with D5LR and oxytocin, ordering diagnostic tests, monitoring the fetal heart tone every 30 minutes, taking vital signs every 4 hours, and keeping the patient NPO during active labor. The nurse carried out the orders by documenting them on the required forms, including the doctor's order sheet, kardex, IV flow sheet, and vital signs record.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 6

    CARRYING OUT OF DOCTORS ORDER

    AND FDAR DOCUMENTATION


    (COTABATO REGIONAL AND MEDICAL CENTER)

    INSTRUCTIONS:
    1. Review the video lecture on carrying-out the doctor’s order and FDAR format of
    documentation.
    2. Carry-out the doctor’s order by filling-out the following forms:
    a. Doctor’s Order
    b. Kardex
    c. IV Flow Sheet
    d. Vital Signs record
    e. IVF tag
    3. Based on the scenario given and doctors order make nurses or progress notes in FDAR
    format using the form below.

    SCENARIO: At around 6: 45 AM , a 25 y.o., G1P0, pregnant woman went to the delivery room due
    to lumbosacral pain, excessive sweating, and facial grimacing . She verbalizes “masakit masyado ang
    tiyan ko'' while holding her abdomen. Her BP is 140 beats/min, respiratory rate of 25 breaths/ min.
    Internal examination revealed 5 cms. dilated, thus she was admitted with the following orders.. (see
    attached DOCTOR'S ORDER SHEET).
    Republic of the Philippines
    Department of Health
    COTABATO REGIONAL AND MEDICAL CENTER

    SURNAME AGE

    GIVEN NAME SEX

    [ ]M[ ]F

    DOCTORS ORDER/NURSES COMPLIANCE SHEET

    (Authenticated all order)

    C- Carried A- administered R- Request made

    E- Endorsed D- Discontinue

    Date C A R E D Time

    Time ORDER Posted

    Signature
    3/28/2020 Chief Complaint (CC)- lumbosacral pain LOP

    7:00am -Please admit under the service of DR. Lu LOP

    -consent to care LOP

    -start venoclysis with D5LR iL; incorporate

    10 units of oxytocin to run at 30 drops / min. LOP

    -Diagnostics/ laboratories

    - CBC, BT and platelet count LOP

    - urinalysis LOP

    -hooked to Electronic Fetal Monitor (EFM) LOP

    -monitor Fetal Heart Tone (FHT) every 30 LOP


    minutes and record please. LOP

    -Vital signs (VS) every 4 hours LOP

    -Nothing per orem (NPO) when in active labor LOP

    -Refer Accordingly LOP

    DR. Marilyn Lu

    Republic of the Philippines


    Department of Health
    COTABATO REGIONAL AND MEDICAL CENTER

    Name of Patient: _____________________________Hospital


    Patient X Record No. ___________
    1234

    INTRAVENOUS FLUID FLOW SHEET


    TYPE OF IVF DATE AND TIME SIGNATURE DATE AND SIGNATURE REMARKS
    HOOKED TIME
    No. CONSUMED

    1 D5LR iL 3-28-20/

    7:00 am
    __________________
    Patient X _____________
    X __________
    X Hospital No. _____________
    1234
    Surname First Name M.I. Room No. _______________
    1

    VITAL SIGNS RECORD

    DATE SHIFT BLOOD CARDIAC/ RESPIRATOR TEMPERATURE O2 PVC Weight Abdominal


    PRESSURE PULSE Y RATE Sat. Girth
    TIME RATE

    3-28- 7-3 140/80 Not 25bpm Not given Not Not Not Not
    20 stated give give given given
    pm Beats/ n n
    mins
    Not stated Not stated
    Not stated
    D5LR 1L
    10 units of oxytocin
    30gtts/min
    03-28-29/7AM

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