Doctor’s Note Doctor’s Order Rationale

7/24/18  Please admit to

ROC under the
7:30 A.m service of
Dr. M
Vital signs:
 TPR q shift & record  To observe and
BP: 90/60 intervene for any
PR: 133 complication that
RR: 22 may process during
T: 37.1 the course of patient
02: 97% receiving treatment

 Monitor I & O q shift  To ensure and keep

& record up with the patient’s
fluid balance,
especially that the
patient has lost
blood

 Diet as tolerated

 IVF PLR 500cc , run  It is a hypertonic,

270 cc x 135 1hr x non-pyrogenic
2hr then solution for fluid and
D5 0.3 Nacl 1L x 100 electrolyte
cc/hr replenishment and
caloric supply in
single dose
containers for
intravenous
administration
 Diagnostics
Chest x-ray PA IL

 Therapeutic :

Salbutamol ml q6

Paracetamol 250 ng
 Paracetamol was
15ml 3.5ml q4 T>
ordered to relieve
38⁰c
patient’s pain
Paracetamol 180 ng
TIV q4 T> 39⁰c

 VS q2 and record

 AP informed of this
admission

 Complete database

 Refer
 Doctor’s Note Doctor’s Order Rationale

7/24/18
 Rounds w/ Dr. M
10:20 A.m

harsh breath sounds  Please do vomit

charting

 Follow up chest
X-ray result

 continuous
Salbutamol
nebulization

 Small feeding

 Monitor fever pattern

 For urinalysis

 Refer
 Doctor’s Note Doctor’s Order Rationale

7/24/18
 IVF TF : D5Nm 1L
2:10 P.m x 55-56 cc/hr

 Cont. present
management

 Refer

7/24/18  Start Cetirizine

syrup 2.5ml BID
6:10 P.m

 For cbc with pc

tom at 8am

 Diet precautions:
diet for age except
dark colored foods

 WOF bleeding ,
decrease BP
 Doctor’s Note Doctor’s Order Rationale

7/25/18  Cont. present

management
6:00 A.m
 Refer

7/25/18  IVF TF: D5Nm 1L

x 55-56cc/hr
12:45 P.m
 Refer

7/25/18

2:13 P.m
 Dr. M updated

 Start Ampicillin 400

mg TIV q6 (-) ANST

 Refer
7/25/18
 Replace loses w/
11:55 Pm present IVF cc per
every vomiting
Vomiting x 1 episode

 IVF to follow:
D5Nm 1L 55-
56cc/hr

 Refer

 Cont. present
management
7/26/18

5:06 A.m

Coughing episode