| 生化 CBC | Flu test,PARAMOL 1tab PO stat. | D50W 4amp IVP stat. | ||||
| 生化 CBC B/C*1 | Flu test,Voren 1pill R stat. | Novamin 1amp IM stat. | ||||
| 生化 CBC EKG | Flu test,PARAMOL 1tab PO stat. | Rolikan 2amp IVP stat. | ||||
| 生化 CBC VBG B/C*1 EKG | 外傷 | Keto 1amp IM stat. | ||||
| 生化 CBC VBG B/C*2 EKG | Wound CD take photo upload. | Vena 1amp in N/S 100ml IVD stat. | ||||
| 生化 CBC PT/aPTT VBG B/C*1 EKG CXR | Wound CD take photo upload.T.T 1dose IM stat. | Primperan 1amp IVP stat. | ||||
| 備血管( LPRBC*2 ) | Wound CD take photo upload.F/U X-ray. | Buscopan 1amp IVP stat. | ||||
| 備血管( FFP*6 ) | Wound CD take photo upload.T.T 1dose IM stat.F/U X-ray. | F/U Anti-HBs(針扎,急產專用)、Anti-HCV(針扎與移植專用)、HIV Ag/Ab Combo Test-針扎,急產HBs Ag (針扎,急產專用)、RPR test(針扎專用)、Anti-HBc(針扎與移植專用)、TPPA test、AST(GOT)、ALT(GPT) | ||||
| 備血管( PLT*12 ) | Wound CD take photo upload.T.T 1dose IM stat.F/U X-ray.CT.sign permit. | F/U HIV Ag/Ab Combo Test-針扎,急產、RPR test(針扎專用)、Anti-HCV(針扎與移植專用)、TPPA test、HBs Ag (針扎,急產專用)。 | ||||
| Ice Packing. | ||||||
| 蒸氣吸入 | Atrovent 1amp + Bricanyl 1amp INH stat. | |||||
| Combivent 1amp INH stat. | Atrovent 1amp + Bricanyl 1amp + Siruta INH stat. | |||||
| Siruta 1amp INH stat. | Combivent 1amp + Siruta 1amp INH stat. | COVID-19 Antigen Rapid Test |
| K: mmol/L. by order give Rolikan 3amp IVP ST.Humulin R U IVP ST.Kalimate Pack PO ST+ | KUB:much stool and gas in colon.經DR.__診視後囑Fleet enema 1 bot STAT. | ||
| 告NPO.N-G decompression | KUB:much stool and gas in colon.經DR.__診視後囑Bisacodyl 1/2 Pill R STAT. | ||
| F/U Troponin-T、CK、CK-MB、EKG. | 患者表Fleet enema / 塞 Bisacodyl 後已有自解糞便。 | ||
| F/U Troponin-T、CK、CK-MB、EKG. K | |||
| F/U Troponin-T、CK、CK-MB、EKG.K . VBG | DR.謝正駿診視後囑Actein 1tab PO STAT+BID.Meptin 1tab PO STAT+BID. | ||
| Urine Pregnancy:Negative.to F/U CT X-RAY. | |||
| F/U CT With/Without Contrast-Brain C-spine Chest Abdomen Plevis，填寫CT同意書。 | |||
| F/U CT Without Contrast-Brain C-spine Chest Abdomen Plevis，填寫CT同意書。 | |||
| F/U CT With/Without Contrast-Brain C-spine Chest Abdomen Plevis，由兩位醫師double sign。 | |||
| 血品回，與另一位護理師核對血型、有效日期、患者出生年月日、病歷號，核對無誤，Vital sign 如生命徵象表單.予以輸 Leukocyte-Poor PRBC / FFP / PLT U.已告知輸血過程中如有呼吸喘、寒顫、全身起疹子等不適應立即告知，KEEP OBS. | |||
| 輸血中，Vital sign 如生命徵象表單，.暫無不適之主訴，KEEP OBS. | |||
| 輸血畢，Vital sign 如生命徵象表單，暫無不適之主訴，Sline clear line，KEEP OBS. |
| CXR:no Patch. | EKG:Normal sinus rhythm. | ||
| CXR:bilateral Increase infiltration. | EKG:Sinus tachycardia. | ||
| CXR:Pneumonia. | EKG:Sinus bradycardia. | ||
| CXR:Cardiomegaly. | EKG:sinus arrhythmia | ||
| CXR:Bronchopneumonia. | EKG:Af RVR. | ||
| KUB:No free air. | EKG:Af SVR. | ||
| KUB:ileus. | EKG:V - V T wave inversion. | ||
| KUB:Much stool. | EKG:1度 AV block. | ||
| EKG:2度1 AV block. | |||
| X-ray:no fracture. | EKG:2度2 AV block. | ||
| X-ray:no finding. | EKG:pacemaker rhythm. | ||
| CT:no ICH. | EKG:RBBB. | ||
| CT:no interal bleeding. | EKG:juntional rhythm. |
| 患者有高危險跌倒風險，已告知患者/家屬上下床應注意安全 |
| Y00158 | Y05292 | Y07672 | Y08536 | ||||
| Y00820 | Y05357 | Y07778 | Y08539 | ||||
| Y00384 | Y04908 | Y08010 | Y08544 | ||||
| Y00733 | Y05754 | Y08034 | Y08550 | ||||
| Y03362 | Y05957 | Y08088 | Y08662 | ||||
| Y02933 | Y06085 | Y07048 | Y08663 | ||||
| Y01540 | Y06205 | Y07062 | Y08571 | ||||
| Y01717 | Y06251 | Y07680 | |||||
| Y04466 | Y06414 | Y08202 | |||||
| Y04682 | Y06415 | Y08442 | |||||
| Y04777 | Y03219 | Y03306 | |||||
| Y05249 | Y07635 | Y08535 |
| Y00409 | |
| Y04289 | |
| Y02697 | |
| Y04080 | |
| Y07050 | |
| Y07197 | |
| Y07224 | |
| Y07496 | |
| Y08241 | |
| Y08497 | |
| Y08570 |
| 今天使用居家快篩呈陽性(有帶快篩匣確認呈陽性) | |
| 今天使用居家快篩呈陽性(出示快篩匣照片確認呈陽性) | |
| 患者已到斗六急診，Vital sign 如生命徵象表單，待照會 |
| 由EMT及檢傷護理持續CPR入急救室，Check pulse(-) , 皮膚呈 濕冷 / 乾冷 / 發紺 , EKG:Asystole / PEA , ambu bagging.由DR.____ 執行On Endo 7.0 / 7.5 # Fix __ cm.Thumper / Lucas USE.Bossmin 1amp IVP Q3M.N/S 500ml IVD STAT. |
| Thumper | Lucas | ||
| EKG:PEA.Bossmin 1amp IVP STAT.Thumper keep use. | EKG:PEA.Bossmin 1amp IVP STAT.Lucas keep use. | ||
| EKG:Asystole.Bossmin 1amp IVP STAT.Thumper keep USE. | EKG:Asystole.Bossmin 1amp IVP STAT.Lucas keep USE. | ||
| EKG:PEA.Thumper keep USE. | EKG:PEA.Lucas keep USE. | ||
| EKG:Asystole.Thumper keep USE. | EKG:Asystole.Lucas keep USE. | ||
| ROSC.check Pulse(+).Check BP:__mmHg.F/U EKG. | EtCO2:__ mmHg. | ||
| Vitacal 1amp IVP STAT.Rolikan 3amp IVP STAT.Humulin R__U IVP STAT.D50W _amp IVP STAT. | ABG data:Glucose: mg/dL.D50W _amp IVP STAT. | ||
