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MD ORDER
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IV PREPARED BY:
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PROGRESS NOTE
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ALLERGIES
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ALLERGIES (OTHER)
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PREGNANT?
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FAINTING WITH NEEDLES/SHOTS?
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In sterile fashion draw each of the nutrients be
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REMOVE 100 cc NS
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ADD 100 cc Sterile Water
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Magnesium Chloride (200 mg/ml) - 4 ml
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Hydroxocobalamin (1mg/ml) - 1 ml
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Dexpanthenol (250 mg/mL) - 2 ml
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Pyridoxide (100 mg/mL) - 2 ml
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Ascorbic Acid (500 mg/ml) -3 ml
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Niacinamide (100 mg/ml) - 3 ml
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Inositol (50 mg/ml) - 3 ml
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Tryptophan (100 mg/ml) - 1 ml
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Taurine (50 mg/ml) - 2 ml
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Glycine (25 mg/ml) - 3 ml
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L-Glutamine (30 mg/ml) - 3 ml
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1.Additional Nutrient & Dose/mL
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1. # mL
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2. Additional Nutrient & Dose/ml
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2. # mL
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3. Additional Nutrient & Dose/ml
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3. # mL
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4. Additional Nutrient & Dose/ml
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4. # mL
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5. Additional Nutrient & Dose/ml
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5. # mL
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SITE OF IV
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IV Started By:
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ANGIOCATH SIZE
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TIME IV STARTED
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TIME IV ENDED
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STARTING BLOOD PRESSURE
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ENDING BLOOD PRESSURE
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STARTING HR
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ENDING HR
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STARTING TEMPERATURE
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ENDING TEMPERATURE
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INFUSION NOTE
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ADDITIONAL INFUSION COMMENTS
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IV DISCHARGE NOTE
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ADDITIONAL DISCHARGE COMMENTS
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PORTACATH NOTE
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FOLLOW-UP
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