IVIG FLOW SHEET - TherapyOM

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ivig FLOW SHEET Form#: CLIN-048C Effective Date: 7/1/12 Approved By: VP of Clinical Operations Revised Date: N/A Karen B. Spano, RPh Patient Name: ________________________________________ _______________Date: __________________________ This form is to be used in conjunction with the Nursing Visit Assessment Report Premeds: N/A Yes Time pre-meds given: __________ Medications given: Diphenhydramine _____mg PO IV Acetaminophen ______mg PO Other route: ___________ Prednisone _______ mg PO Other: ______________________________________PO IV ivig : Brand___________________________________ ____ Dose:_________ grams in ____________mls IV to infuse over ________hours via Gravity R egulator ( dial-a-flow) Pump (model): ___________________________ every (enter frequency) __________________________ Diluent As Provided by Manufacture: Yes NO If no, diluent used.

IVIG FLOW SHEET Form#: CLIN-048C Effective Date: 7/1/12 Approved By: VP of Clinical Operations Revised Date: N/A Karen B. Spano, RPh Patient Name: _____Date: This form is to be used in conjunction with the Nursing Visit Assessment Report

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