Home Infusion referrals Please complete information below "*" indicates required fields Patient Name:* Drug:* Date of Birth* MM slash DD slash YYYY Dose:* Address:* Frequency:* City:* End of Therapy Date:* State:* Zip:* Diagnosis:* Diagnosis Code:* Phone*Alternate Phone:Following MD:* Caregiver:* Phone*Phone(if different)Pt. Height* Pt. Weight* Allergies* Flushing Orders: Normal Saline 0.9% up to 10ml IV per SAS(H) protocol. 10ml IV after lab draw and as needed Heparin (10 U/ml if pediatric, l00U/mL if adult), 5ml IV per SASH protocol. Other: Labs: Every Monday (Only draw labs specific to IV therapy) All Antibiotic Therapies - CMP, CBC w/ diff, CRP, ESR If on Vancomycin - CMP, CBC w/ diff, CRP, ESR, CK, trough weekly/PRN If on Daptomycin or Gentamycin - CMP, CBC w/ diff, CRP, ESR, CK If on TPN - CMP, CBC w/ diff, ESR, CRP, Mag, Phos, Triglycerides Skilled Nursing: Skilled nursing has been arranged with: HIT Specialists to arrange Skilled Nursing. Nursing to instruct patient / caregiver in administration of therapy, troubleshooting, catheter management and signs/symptoms of complications related to therapy and assess response to therapy.Additional Orders: Convert to catheter care maintenance if infusion therapy is complete and line access needs to be maintained. Flush each lumen daily with Normal Saline± Heparin. DC PICC at conclusion of prescribed therapy. Other: Prescriber Signature: Date: Prescriber Name: NPI: Phone: Fax: CAPTCHA
