<p> PATIENT LABEL HERE TELEMETRY ORDERS (Medical-Surgical)</p><p>The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked. Initial all handwritten order modifications and the bottom of each page when indicated (multipage).</p><p>1.  Telemetry monitoring without pulse oximetry  Telemetry monitoring with pulse oximetry </p><p>2. Please choose appropriate indication below: Syncope with one of the following:  Congestive heart failure, ventricular tachycardia, systolic blood pressure < 90, second or third degree heart block, heart rate < 45 or heart rate > 120  Syncope with normal physician exam, normal EKG or previously normal echocardiogram  Asymptomatic second or third degree heart block New onset atrial fibrillation/flutter, uncontrolled chronic atrial fibrillation/flutter, sustained ventricular  tachycardia Post-operative patients with one of the following: angina, new EKG changes, positive pre-operative stress  test, systolic blood pressure < 90 or heart rate > 130  Initiation of antiarrythmic medications or other medications that may prolong QT interval  External pacemaker  Acute myocardial infarction, chest pain, rule out myocardial infarction, unstable angina  Decompensated congestive heart failure Post-operative patients with one of the following:  Previous history of coronary artery bypass graft, percutaneous coronary intervention, valve repair/ replacement  Symptomatic bradycardia (heart rate < 45) or symptomatic tachycardia (heart rate > 120)  Cardiac contusion  Ischemic or hemorrhagic strokes (with potential for arrhythmia)  Myocarditis or pericarditis  Step down from Intensive Care with recent cardiac or respiratory arrest  Post coronary angiography, post ablation/cardioversion, post defibrillator/pacemaker placement  Suspected or diagnosed sleep apnea  Drug toxicity with arrhythmia  Electrolyte abnormality: Potassium < 3.0 or > 6.0, Calcium < 7.0 or > 11.0, Magnesium < 1.3 or > 3.0 Other (list here): </p><p>______Date Time Physician Signature PID Number</p><p>*1-36084* FORM 1-36084 REV. 01/2016 Page 1 of 1</p>