Patients Full Legal NameNo nicknamesExample Barbara A Lutz

Date of BirthTests RequestedOrdering Providers signature

If the signature is not ledgible, please write the providers name also

2

DiagnosisNarrative ICD code

Please also indicate if any additional copies should be sent to another provider for continued care of the patient eg cc Dr. Hunter

Patients Phone NumberSo departments can schedule if required

3

Please fax orders to the following locationsRehab services 530-2040 (Salida)Rehab services 395-6348 (Buena Vista)Laboratory 530-2201Imaging 530-2203Cardio/Pulmonary 530-2282Buena Vista Health Center 395-9064Specialty Clinic 530-2292

4

Special Requirements for Imaging Orders:CT Abdomen DOES NOT cover pelvisIf CT Abdomen and Pelvis is needed; the order

must state this3D reconstruction must be requested on the

orderConsult Radiologist with contrast questions

5

Special Order Requirements for Cardio/Pulmonary Orders:Physician History and Physical form must be

attached to all sleep study ordersNeck circumference must be listed on history and

physical formSleep or non sleep deprived must be listed on

EEG orders“Hyperventilate” or “no hyperventilate” must be

listed on EEG order

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Special Order Requirements for Cardio Pulmonary Orders continued:Echogram orders must be ordered as limited or

completeExercise oximetry can be ordered with Treadmills

7

Special Order Requirements for Rehab Services (PT, OT and Speech Therapy):Include patient phone number of the order so

rehab services can schedule the patientInclude frequency and duration of visitsICD code is helpful. A surgical diagnosis MUST be

accompanied by a diagnosis which explains the reason for the surgery and therefore the need for rehab. DO NOT use surgical diagnosis exclusively.

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Special Order Requirements for Rehab Services (PT, OT and Speech Therapy) continued:For complex patients, rehab CAN NOT evaluate

and treat a neck, shoulder and hip all in one day. Please choose the most acute/debilitating injury. eg prioritize 1. shoulder 2. neck 3. hip

Indicate if patient has a preference for rehab services locationeg Salida or Buena Vista

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Special Order Requirements for Lab/ Pathology:Two unique identifiers must be on all specimens

collected and sent to HRRMC for testingLast Menstrual Period for Pap SmearsSite for Pathology Specimens

eg-Left scalpDate and time of specimen collection

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On Line Laboratory Test Catalog http://www.hrrmc.com

ServicesDiagnostic ServicesLaboratory Test Catalog

Work in Progress

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HRRMC Order Expiration by Department

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Department Order Type Expiration

Cardio/Pulmonary

Cardiac and Pulmonary Rehab

One year

Other Cardio/Pulmonary Orders

90 days

Lab Standing orders One year

One time lab orders 90 days

Radiology All orders 6 months

Rehab Services All orders 90 days

Pharmacy Medication orders One year

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