Please Use Ball Point Pen!
DATE/TIME
PHYSICIANS MUST SIGN, Date and Time ALL ORDERS Please Use Ball Point Pen!
CHK'D BY
PHYSICIAN'S ORDER SHEET
Psychiatric Treatment Order Set
Order Set No. 10462
Allergies:
Reactions:
Allergies:
Reactions:
Emergency Department
Admitting M.D.:/DO/DDS
Attending M.D.:/DO/DDS
Referring M.D.:/DO/DDS
1. Emergency Detention due to potential danger of harm to self and/or others
 Yellow gown and secure belongings
 UDS
 Home medication reconciliation
 Safe tray
 Scan transfer authorization form
 Sitter with constant observation
 Alcohol, serum
 Breath alcohol
 Fingerstick glucose Q12 (if diabetic)
 Consult Crisis response team
2. Vitals q 12 hours
3. Psychosocial assessment per nursing q 12 hours
4. Call physician IF
Temp > 100.5 F or < 96.0 F
Systolic BP > 180mmHg or < 90mmHg
Diastolic BP > 100mmHg or < 40mmHg
HR > 110bpm or < 50bpm
RR > 24 or < 8 per minute or
SpO2 < 90%.
Precautions
 Suicide
 Assaultive
 Seizure
 Elopement
 Fall Risk
 Other:
Page1 of 4
New: June 2017
PROHIBITED:
MS, MgSO4
MS, MSO4
U
IU
INSTEAD WRITE
magnesium sulfate
morphine sulfate
units
international units
Physician’s Signature
PROHIBITED ABBREVIATIONS
PROHIBITED:
Q.D.
QOD
.5 mg
5.0 mg
INSTEAD WRITE
daily
every other day
0.5 mg – always use zero before decimal
5 mg – never use trailing zeroes
Revised: 4/2014
PHYSICIAN'S ORDER SHEET
THE PHARMACY IS AUTHORIZED TO DISPENSE DRUGS FOR ADMINISTRATION OF
ANOTHER GENERICALLY EQUIVALENT BRAND, IDENTICAL IN STRENGTH, DOSAGE
FORM, AND CONTENT OF ACTIVE THERAPEUTIC INGREDIENT(S).
*PO2300*
PO2300
Physician Orders
Patient Identification
Please Use Ball Point Pen!
DATE/TIME
PHYSICIANS MUST SIGN, Date and Time ALL ORDERS Please Use Ball Point Pen!
CHK'D BY
PHYSICIAN'S ORDER SHEET
Psychiatric Treatment Order Set
Order Set No. 10462
Allergies:
Reactions:
Allergies:
Reactions:
Emergency Department
Diet
 Regular diet
 Low sodium 2gm diet
 Diabetic 2000kcal diet
Medications
 Nicotine Patch 14mg patch topical daily for ≤ 20 cigarettes/day
OR
 Nicotine Patch 20mg patch topical daily for > 20 cigarettes/day
 Acetaminophen 650mg po q4 hours PRN for pain level 0-4, Max APAP 3g/24hrs
 Ibuprofen 400mg po q4 hours PRn for pain level 0-4
 Trazodone 50mg po qhs PRN insomnia; May repeat x1 in 1 hour if not effective for sleep
Consider restarting home medications for chronic medical condition if no contraindications.
If BP <160 and history of opiod use, consider:
 Clonidine 0.1mg po q6 hours PRN for Systolic BP > 160 mmHg
or Diastolic BP > 95 mmHg
Mild to Moderate Agitation
(For PRN use in those patients experiencing mild to moderate agitation or dangerous
Behavior, consenting to oral medications.)
Check only one regime
 Haloperidol 5mg PO Q4 hrs PRN agitation
 Quetiapine 50mg PO Q2 hrs PRN agitation (Geripsych neurocognitive disorder)
 Risperidone disintegrating tab 2mg PO q12 hours PRN agitation
 Olanzapine disintegrating tab 10mg PO q12 hours PRN agitation
With optional addition of:
 Lorazepam 2mg PO q4 hours PRN agitation
Page 2 of 4
New: June 2017
Physician’s Signature
PROHIBITED:
MS, MgSO4
MS, MSO4
U
IU
INSTEAD WRITE
magnesium sulfate
morphine sulfate
units
international units
PROHIBITED ABBREVIATIONS
PROHIBITED:
Q.D.
QOD
.5 mg
5.0 mg
INSTEAD WRITE
daily
every other day
0.5 mg – always use zero before decimal
5 mg – never use trailing zeroes
Revised: 4/2014
Patient Identification
PHYSICIAN'S ORDER SHEET
THE PHARMACY IS AUTHORIZED TO DISPENSE DRUGS FOR ADMINISTRATION OF
ANOTHER GENERICALLY EQUIVALENT BRAND, IDENTICAL IN STRENGTH, DOSAGE
FORM, AND CONTENT OF ACTIVE THERAPEUTIC INGREDIENT(S).
*PO2300*
PO2300
Physician Orders
Please Use Ball Point Pen!
DATE/TIME
PHYSICIANS MUST SIGN, Date and Time ALL ORDERS Please Use Ball Point Pen!
CHK'D BY
PHYSICIAN'S ORDER SHEET
Psychiatric Treatment Order Set
Order Set No. 10462
Allergies:
Reactions:
Allergies:
Reactions:
Emergency Department
Extreme Agitation or Dangerous Behavior
(for PRN use in those patients experiencing moderate to extreme agitation or
dangerous behavior and who likely lack capacity to consent to treatment.)
 Haloperidol 5mg PLUS Lorazepam 2mg PLUS Diphenhydramine 25mg IM every
2 hours PRN agitation
Extreme Agitation or Dangerous Behavior (Cont.)
 Ziprasidone 20mg IM PLUS Lorazepam 2mg IM every 12 hours
(Dose related QTc prolongation and risk of cardiac arrhythmias with Ziprasidone)
 Olanzapine 10mg IM q 8 hours PRN agitation
Alternative for extreme combative/violent behavior:
 Ketamine 4mg per kg IM
WEIGHT:
(Monitor bp and O2 status. In most cases, only effective for initial control.)
Mood Stabilization (may use alone or in combination with any of those below)
 Divalproex Sodium 1000mg PO at completion of physical and mental assessment.
(Contraindicated in severe hepatic impairment: Child-Pugh Class C)
(Caution in women of childbearing age who may be or become pregnant.)
Mood Stabilization and/or Treatment of Psychosis (choose only one)
 Lurasidone 40mg PO dail7
(Consider use in women of child bearing age who may be or become pregnant.)
 Risperdone 1mg PO BID
OR
 Risperidone 0.5 PO BID (for patients with severe hepatic impairment)
 Haloperidol 5mg PO BID (only indicated for psychosis)
Page 3 of 4
New: June 2017
PROHIBITED:
MS, MgSO4
MS, MSO4
U
IU
INSTEAD WRITE
magnesium sulfate
morphine sulfate
units
international units
Physician’s Signature
PROHIBITED ABBREVIATIONS
PROHIBITED:
Q.D.
QOD
.5 mg
5.0 mg
Revised: 4/2014
Patient Identification
PHYSICIAN'S ORDER SHEET
THE PHARMACY IS AUTHORIZED TO DISPENSE DRUGS FOR ADMINISTRATION OF
ANOTHER GENERICALLY EQUIVALENT BRAND, IDENTICAL IN STRENGTH, DOSAGE
FORM, AND CONTENT OF ACTIVE THERAPEUTIC INGREDIENT(S).
*PO2300*
PO2300
Physician Orders
INSTEAD WRITE
daily
every other day
0.5 mg – always use zero before decimal
5 mg – never use trailing zeroes
Please Use Ball Point Pen!
DATE/TIME
PHYSICIANS MUST SIGN, Date and Time ALL ORDERS Please Use Ball Point Pen!
CHK'D BY
PHYSICIAN'S ORDER SHEET
Psychiatric Treatment Order Set
Order Set No. 10462
Allergies:
Reactions:
Allergies:
Reactions:
Emergency Department
For prevention of extrapyramidal side effects and to promote mild sedation
 Diphenhydramine 50mg PO BID
OR
 Benztropine 1mg PO BID
For geriatric agitation in context of major neurocognitive disorder:
 Quetiapine 50mg PO BID
AND
 Quetiapine 200mg PO at HS (Hold if sedated)
Page 4 of 4
New: June 2017
PROHIBITED:
MS, MgSO4
MS, MSO4
U
IU
INSTEAD WRITE
magnesium sulfate
morphine sulfate
units
international units
Physician’s Signature
PROHIBITED ABBREVIATIONS
PROHIBITED:
Q.D.
QOD
.5 mg
5.0 mg
Revised: 4/2014
Patient Identification
PHYSICIAN'S ORDER SHEET
THE PHARMACY IS AUTHORIZED TO DISPENSE DRUGS FOR ADMINISTRATION OF
ANOTHER GENERICALLY EQUIVALENT BRAND, IDENTICAL IN STRENGTH, DOSAGE
FORM, AND CONTENT OF ACTIVE THERAPEUTIC INGREDIENT(S).
*PO2300*
PO2300
Physician Orders
INSTEAD WRITE
daily
every other day
0.5 mg – always use zero before decimal
5 mg – never use trailing zeroes