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Appendix B: Continued
R Request for Physician/NP/PA Orders
Orders were provided by clinician through ❑ Phone ❑ Fax ❑ In Person
❑ Other____________________________
❑
Order UA
❑
Urine culture
❑
Encourage ________ ounces of liquid intake ________ times daily until urine is
light yellow in color.
❑
Record fluid intake.
❑
Assess vital signs for ________ days, including temp, every ________ hours for
________ hours.
❑
Notify Physician/NP/PA if symptoms worsen or if unresolved in ________ hours.
❑
Initiate the following antibiotic
Antibiotic:__________________________________ Dose: _______________
Route: ________ Duration: _________________________________________
❑ No ❑ Yes Pharmacist to adjust for renal function
❑
Other __________________________________________________________
Physician/NP/PA signature Date/Time
___________________________________________________________________
Telephone order received by Date/Time
___________________________________________________________________
Family/POA notified (name) Date/Time
___________________________________________________________________
Source: Toolkit 1. Suspected UTI SBAR Toolkit. 2016. Available at: https://www.ahrq.gov/
nhguide/toolkits/determine-whether-to-treat/toolkit1-suspected-uti-sbar.html. Accessed
November 10, 2018.
