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Lydia Smith  Physician's Orders
12/20/95
Allergies: Prozac
Admit to Geropsych unit per Dr. Weitzel
Condition: Poor
Preliminary Diagnosis: Anxiety disorder
Activity: Ad lib
Diet: Regular, soft meats
Labs:CBC, Chem 20, RPR, T7, TSH, Digoxin Level, Urinalysis with Culture and Sensitivity if indicated EKG. 
AIMES Test
Occupational Therapy evaluation and treatment.
Medication: Tylenol 1-2 by mouth every 4 hours as needed for pain. 
Mylanta 30cc by mouth every 4 hours as needed for dyspepsia.
Milk of Magnesia 30 cc by mouth every bedtime as needed for constipation.
Special Precautions: Every 15 minute vital signs for 24 hours.
Vital Signs: Twice a day.
Chest X-ray
Lasix 40 mg by mouth every morning
Potassium chloride 8 meq by mouth every morning
Lanoxin 0.125 mg by mouth every morning
Normodyne 200 mg by mouth twice a day. 
Vasotec 10 mg by mouth every morning. 
Risperdal 0.5 mg by mouth every morning, 1700 and bedtime. 
Vasotec 10 mg by mouth, every day as needed, for blood pressure greater than 175/100.
Serzone 100 mg by mouth twice a day.
Ativan 1 mg to 2 mg intramuscularly every 6 hours as needed for severe agitation. 
Telephone order Dr. Weitzel
1745 Bonnie Hardy, RN
Signed Robert Weitzel, MD
12/20/95 1815 Noted Bonnie Hardy, RN

24 hour check 12/21/95 0330 T. Scholl, RN
 

  
 
 

I CERTIFY THAT THIS PATIENT NEEDS INPATIENT ACUTE CARE HOSPITAL SERVICES. 
Signed: Robert Weitzel,M.D.
Date: 12/20/95
 
 

 
12/21/95
1. Cipro 500 mg by mouth twice a day for six doses. 
2. Risperdol 1 mg by mouth every morning, 1700, and every bedtime. 
Thanks, 
Signed Robert Weitzel, MD
Noted: D Kley, RN 12/21/95 2320

12/21/95 
Aspirin 1 a day by mouth Error RW
Signed Robert Weitzel, M.D.

24 hour check 12/22/95 0430 T. Scholl, RN

24 hour check 12/23/95 0400 L. Long, RN

24 hour check 12/24/95 0200 L.Long,RN

12/24/95
1. Urinalysis tomorrow, culture and sensitivity if indicated. 
2. Trazodone 100 mg by mouth every bedtime, may repeat once as needed for sleep.
Thanks,
Signed Robert Weitzel, M.D. 
12/24/95 1930 Noted Bonnie Hardy, RN

12/24/95
1. May straight catheterize for urine.
2. Posey restraint in bed tonight, for protection of self ( against falls) 
Thanks, 
Robert Weitzel, M.D.
12/24/95 1930 noted B. Hardy, RN

24 hour check 12/25/95 0155 T. Scholl, RN

 

    
12/25/95 1130 
Telephone Order: Dr. Weitzel to Lynn Long, RN
If patient refuses Risperdol give Haldol 2 mg intramuscularly.
Noted: L. Long, RN 12/25/95 1130
Signed Robert Weitzel, MD

24 hour check 12/26/95 0115 T. Scholl, RN

24 hour check 12/27/95 0145 B. Hardy, RN

AUTOMATIC DRUG STOP ORDER
Patient: Lydia Smith Room 311-2
Drug(s) Exp. Date Last Dose
1. Ativan 1-2 mg IM q 6 hrs prn agitation
2. 
3. 
4.
According to hospital policy orders for these medications must be reordered or they will be discontinued.
Signature: Robert Weitzel, M.D.

12/27/95
Sputum culture: Signed Robert Weitzel, MD
Noted 12/28/95 0100 T. Scholl, RN

24 hour check 12/28/95 0140 T. Scholl, RN

24 hour check 12/29/95 0240 T. Scholl, RN

12/29/95 
1. Depakote Depakene 125 mg by mouth
every morning and every1700 then 500 mg by mouth every bedtime. 
2. Haldol 3 mg intramuscularly at morning, 1700 and bedtime if patient refuses oral Risperdol.
3. Haldol 5 mg by mouth or intramuscularly every 6 hours as needed for severe agitation. 
4. Cogentin 1 mg by mouth or intramuscularly every 6 hours as needed for severe extrapyramidal symptoms.
Signed Robert Weitzel, MD
Noted L. Wilson, RN 12/30/95 0030
 

  
 
 
 
 
 
 
 
 
 
 
 

Expiration Date
12/27/95
Noted: 12/27/95 1100 
Sheila Hansen, RN
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
24 hour check 12/30/95 0615 T. Scholl, RN

AUTOMATIC DRUG STOP ORDER
Patient: Lydia 
Drug(s) Exp. Date Last Dose
1.Lasix 40 mg 12/30 
2. Kcl 8 meq q am 12/30
3.Lanoxin 0.125 mg q am 12/30
4.Normodyne 200 mg bid 12/30
According to hospital policy orders for these medications
must be reordered or they will be discontinued.
Signature: Robert Weitzel, M.D.

    
AUTOMATIC DRUG STOP ORDER
Patient: Lydia 
Drug(s) Exp. Date Last Dose
1.Vasotec 10 mg q am 12/30
2. Serzone 100 mg bid 12/30
3.Tylenol 1-2 po q 4 prn pain 12/30
4.MOM 30 cc qhs prn constip. 12/30
According to hospital policy orders for these medications
must be reordered or they will be discontinued.
Signature: Robert Weitzel, M.D.		    
AUTOMATIC DRUG STOP ORDER
Patient: Lydia 
Drug(s) Exp. Date Last Dose
1. Mylanta 30 cc po q4 prn dyspepsia 12/30. Vasotec 10 mg q d prn BP > 175/100 12/30
3.
4.
According to hospital policy orders for these medications must be reordered or they will be discontinued.
Signature: Robert Weitzel, M.D.
12/30/95 1335
Noted B. Hardy, RN		    
24 hour check L. Wilson, RN 12/31/95 0145

AUTOMATIC DRUG STOP ORDER
Patient: Lydia Smith Room 
Drug(s) Exp. Date Last Dose
1. Risperdol 1 mg po q am, 1700, hs 
2. If pt refuses give Haldol 3 mg IM (see PRN)
3.
4.
According to hospital policy orders for these medications must be reordered or they will be discontinued.
Signature: Robert Weitzel, M.D.
12/31/95 1345 Noted B. Hardy, RN

24 hour check L. Wilson, RN 0700 1/1/96

1/1/96
1. Increase Depakene to 250 mg by mouth every morning, 250 mg by mouth every 1700 and Depakene 500 mg by mouth every bedtime. 
2. Please get Valproic Acid level in morning on 1/4/96.
Thanks, Robert Weitzel, M.D.
Noted: L. Long, RN 1/1/96 1730

1/1/96 2300 Telephone order Dr. Weitzel
If patient refuses Risperdol give 5 mg intramuscular Haldol.
Signed Robert Weitzel, MD
Noted: L. Long, RN 1/1/96 2300

1/2/96 0100 24 hour (check) L. Wilson, RN

  
 
 
 
 
 
 
 
 
 
 

 
1/2/96 1630 
Order clarification: If patient refuses Risperdol by mouth give 5 mg Haldol intramuscularly.
Telephone order Dr. Weitzel, B. Hardy, RN
Signed Robert Weitzel, MD
1/2/96 noted B. Hardy, RN 1630 

24 hour check 1/3/96 0310 T. Scholl, RN

AUTOMATIC DRUG STOP ORDER
Patient: Lydia 
Drug(s) Exp. Date Last Dose
.Trazodone 100 mg qhs 1/3
2.Trazodone 100 mg qhs MRx1 prn sleep 1/3 
3.Ativan 1-2 mg IM q6 prn severe agitat. 1/3
4.
According to hospital policy orders for these medications must be reordered or they will be discontinued.
Signature: Robert Weitzel, M.D.

1/3/96 
1. Serzone 150 mg twice a day 
2. Trazodone 50 mg by mouth every morning 50 mg by mouth every 1700 and 150 mg by mouth every bedtime. 
3. Depakene (Valproic acid) level in morning
Thanks, Robert Weitzel, MD

1/3/95 
Clonidine transdermal patch 0.2 mg per dermis every 3 days. Error R.W. every week. 
Thanks, Robert Weitzel, M.D. 
1200 1/3/96 (Nurse, signature cut off page)

    
24 hour check 1/4/96 0415 T. Scholl, RN

24 hour check 1/5/96 0420 T. Scholl, RN

24 hour check 1/6/96 0255 T. Scholl, RN

24 hour check 1/7/96 2400 L. Wilson, RN

1/7/96 
Morphine sulfate 5 mg intramuscularly every 3 hours around the clock.
Thanks, Robert Weitzel, MD

1/7/96 Hold all other meds (other than Morphine sulfate) 
Do not resuscitate 
Thanks, Robert Weitzel, MD
1/7/96 Earline Cozzins, RN 2130

1/8/96 24 hour check 0200 L. Wilson, RN

1/8/95 0900
Give Morphine sulfate 10 mg intramuscularly each 3 hours around the clock 
Telephone order Dr. Weitzel 
Mistaken Entry

    
1/8/95 0900 
Change Morphine sulfate order to Morphine sulfate 10 mg every 3 hours around the clock. 
Telephone order Dr. Weitzel 
Sheila Hansen, RN
Signed Robert Weitzel, MD 
Noted 0900 1/8/95 Sheila Hansen, RN
 
 
 
 

1/9/96
Release patient=s body to mortuary
Signed Robert Weitzel, MD
Noted 1/9/96 1230 Sheila Hansen, RN

  
 
 

1/8/96 1350 
Asked to see patient 
No vital signs 
Patient with family
Plan - Discharge to mortuary
Signed, Dr. B. Nielson, MD 
1/8/96 1350 (Unknown Nurse Signature) 
     

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