Pinnacle HomeCare - Invasive Ventilation Pediatric Order

Pinnacle HomeCare

RX ORDER FORM: PEDIATRIC INVASIVE VENTILATION
SUBMIT TO: INFO@THEPINNACLEHOMECARE.COM
FAX: 833-230-2622
QUESTIONS? CALL (609) 239-7588
PATIENT DEMOGRAPHICS & DIAGNOSIS
Chronic Respiratory Failure (J96.10)
Tracheostomy Status (Z93.0)
Neuromuscular Disorder (ICD-10: )
Other (ICD-10: )
VENTILATOR SETTINGS Length of Need: 99 Months (Lifetime)
Parameters Setting 1 (Primary/Home) Setting 2 Setting 3 (Travel)
Mode
Rate
VT (Tidal Vol)
PEEP
I-Time
LPM / FiO2
RT to adjust unspecified parameters (Rise Time, Trigger, Flow) & Alarms for safety.
RT to modify settings to synchronize patient with ventilator.
OXYGEN THERAPY
Oxygen Concentrator ( LPM)
Portable Tanks (Circle: E / D / M)
Usage: Continuous Nocturnal (PRN not covered by insurance)
TRACHEOSTOMY TUBES (Qty: 1/mo)
Primary: Brand/Size: Ref#:
Backup: Brand/Size: Ref#:
VENT & TRACH SUPPLIES (Monthly)
Ventilator Circuit
Bacterial/Viral Filter
Active Heated Humidifier
Vent HME (Ref: )
Trach HME (Ref: )
Trach Ties (Ref: )
Trach Care Kits
Mepilex Dressing (Ref: )
Saline Bullets (Small)
Individual Lubricant Packets
SUCTION (Qty: Monthly)
Suction Machine (Bedside & Portable)
Suction Canisters
Suction Tubing
Yankauer Catheters
Suction Filters
Oral/Nasal Adapter w/ cover
Suction Catheters:
Closed System (Size: Fr)
Standard Trach (Size: Fr)
ENTERAL NUTRITION
Formula:
Route: G-Tube J-Tube NG-Tube
Method: Pump Bolus/Syringe
Schedule: mL/hr x hrs/day
Syringes: 1ml 3ml 5ml 10ml 60ml
ADDITIONAL DME
Cough Assist Device
Pulse Oximeter: Bedside Portable
EtCO2 Capnograph
Nebulizer Compressor (Mask / T-Piece)
Oxygen Qualification: I certify that qualifying testing is documented in the medical record (SpO2 ≤88% on room air at rest or exertion). Testing is dated within 60 days of discharge.
Confidential Information: This attachment contains privileged and confidential information and/or PHI for Pinnacle HomeCare. If you are not the intended recipient, please notify Pinnacle HomeCare at (609) 239-7588.