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ALLERGIES
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ALLERGIES (OTHER)
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PROGRESS NOTE
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MD ORDER
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In sterile fashion draw each of the nutrients be
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IV PREPARED BY:
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Hydroxocobalamin (1mg/ml) - 1 ml
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Riboflavin (50 mg/ml) - 2 ml
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Pyridoxide (100 mg/mL) - 2 ml
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Metoclopramide (5 mg/ml) - 2 ml
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Ondansetron (2 mg/ml) - 2 ml
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Ketorolac (30 mg/ml) - 1 ml
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5-MTHF (500 MCG) - 2 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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AFTER IV: Glutathione (200 mg/ml) - 5 cc SLOW
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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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