Doctor S Orders & Flow Sheet

Massachusetts General Hospital Doctor’s Orders & Flow sheet The MGH Translational & Clinical Research Centers

SPID #

PROTOCOL INFORMATION SPID# Visit# Study Fund #: Admit to TCRC: Date:______Time:______□ Outpatient □ Inpatient Diagnosis: Study Title: Appts / Tests: Consent in chart – verify expiration date □ ID Band on & checked □

Code Status / Allergies / Prior to Admission Medications: in EPIC Diet: Activity: Discharge: Labeling/Processing: see Processing Instructions. MD/NP signature not required for Processing Instructions.

Visit Specific Orders:

Visit Specific Flow sheet Role Procedure Timepo Time Comments int Done

Signature must be original. No electronic or stamped signatures permitted.

MD/NP Printed Name:______MD/NP Signature: ______Beeper#______RN Initials:______RN Printed Name:______RN Signature:______RN Initials:______RN Printed Name:______RN Signature:______RD Initials:______RD Printed Name:______RD Signature:______Version: 1.1

Massachusetts General Hospital Doctor’s Orders & Flow sheet The MGH Translational & Clinical Research Centers

SPID # Tube: Indicate Test: Processing Special Storage/Send To: specimen type instructions: instructions: (urine/ blood/ CSF..), tube color, size and amount

Name of test: Clot: Label each tube and Spin: aliquot with: Name, Code of test: Aliquot: MRN, Date, SPID#, Temp: V#, Tube, Test, Time point Name of test: Clot: Label each tube and Spin: aliquot with: Name, Code of test: Aliquot: MRN, Date, SPID#, Temp: V#, Tube, Test, Time point Name of test: Clot: Label each tube and Spin: aliquot with: Name, Code of test: Aliquot: MRN, Date, SPID#, Temp: V#, Tube, Test, Time point

Name of test: Clot: Label each tube and Spin: aliquot with: Name, Code of test: Aliquot: MRN, Date, SPID#, Temp: V#, Tube, Test, Time point Name of test: Clot: Label each tube and Spin: aliquot with: Name, Code of test: Aliquot: MRN, Date, SPID#, Temp: V#, Tube, Test, Time Page 3 of 4

Signature must be original. No electronic or stamped signatures permitted.

MD/NP Printed Name:______MD/NP Signature: ______Beeper#______RN Initials:______RN Printed Name:______RN Signature:______RN Initials:______RN Printed Name:______RN Signature:______RD Initials:______RD Printed Name:______RD Signature:______Version: 1.1