_00419_phy_nonviablelivebirth

_00419_phy_nonviablelivebirth - PHYSICIAN ORDER SHEET FOR...

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Unformatted text preview: PHYSICIAN ORDER SHEET FOR NON-VIABLE LIVE BIRTHS Admit; Comfort Care Status. Provide comfort care per Protocol for “Non-Aggressive” Perinatal Management. Heart Rate and respirations q 30 minutes. Notify mother’s primary physician if infant alive at 2 hours of age or sooner if indicated. Call mother’s primary physician or designee for pronouncement of death. No Code Status, to include no mechanical or chemical resuscitation, no intubation or defibrillation. Genetic evaluation and autopsy, if parent(s) consent. Date Time Signature ZZ00419 (6/13/05) Patient Identification SAFH SDH SMCS SRMC Physician’s Orders Non-Viable Live Births Page 1 of 2 ORDERS DATE: _________________________ TIME: _________________________ REASON FOR ADMISSION: ________________________________________________________________ _______________________________________________________________________________________ WEIGHT: _____________ LENGTH: _____________ HEAD CIRCUMFERENCE: _____________________ PHYSICIAN ASSESSMENT: _________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ OBSERVED ANOMALY? YES NO IF YES: ______________________________________________________________________ (Document discussion with patient/family) CODE STATUS: ___________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Comfort Care administered HOSPITAL COURSE: ______________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ CAUSE OF DEATH: ________________________________________________________________________ DATE/TIME OF DEATH: _____________________________________________________________________ Print Physician Name Physician Signature ZZ00419 (6/13/05) Patient Identification SAFH SDH SMCS SRMC Comfort Care Form; H & P, Progress Notes & Discharge Summary Page 2 of 2 ORDERS ...
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