Cardiopulmonary Orders - Emory Johns Creek Hospital

EmoryJohnsCreek.com
Cardiopulmonary Orders
ATTENTION PATIENTS: Please remember to bring this form with you to the hospital for your test. Your test may be delayed
or cancelled if we do not have this form.
Patient Name:
Diagnosis:
ICD-9 Code: Precert #:
Ordering Physician:
Patient Contact Number:
Precert needed: Yes No
Referral needed: Yes No
Physician Phone Number: STAT Call Report to: Yes No #:
Physician Signature and Date: NPI #:
ATTENTION PHYSICIAN OFFICES: Please select tests below.
Call Patient to Schedule
Cardiac Echo
Complete Echo
Complete Echo with Bubble Study
Stress Echo
Dobutamine Echo
Trans Esophageal Echo (TEE)
Other:___________________________________
Treadmill
Exercise Treadmill
Nuclear Medicine
Nuclear Dual Isotope Stress Test
Nuclear Adenosine
Nuclear Adenosine Walking
Nuclear Dobutamine
Nuclear Thallium Viability Study
Nuclear MIBI-MIBI
Nuclear Persantine
Other:___________________________________
EKG
EKG
Syncope Study
Tilt Table
Pulmonary Services Studies
Baseline Spirometry
Spirometry Pre & Post Bronchodilator
Complete Pulmonary Function
Complete Pulmonary Function with ABG
Arterial Blood Gas
Other:___________________________________
Neurodiagnostic
Routine EEG
EEG Sleep Deprived
Ambulatory EEG
Physician Office should obtain precerts for exams scheduled less than 24 hours in advance.
CALL TO SCHEDULE: 678-474-8100 FAX ORDERS TO: 678-474-8101
INSTRUCTIONS FOR PATIENT PREP ON REVERSE

CARDIAC ECHO:
PREP INSTRUCTIONS FOR ADULT PATIENTS
No special preparation.
STRESS / DOBUTAMINE ECHOCARDIOGRAM:
1. Do not eat, drink or smoke 4 – 6 hours prior to test.
2. With approval from your physician, stop taking beta-blocker medications 24
hours prior to test.
3. Wear comfortable clothing/shoes if walking on treadmill.
NUCLEAR STRESS TEST:
1. Do not eat, drink or smoke 4 - 6 hours prior to test.
2. With approval from your physician, stop taking beta-blocker medications 24
hours prior to test.
3. Wear comfortable clothing/shoes to walk on treadmill.
NUCLEAR SCAN ADENOSINE:
1. Do not eat, drink or smoke 4 – 6 hours prior to test.
2. With approval from your physician, stop taking xanthine medications 24 hours
prior to test.
NUCLEAR SCAN DOBUTAMINE:
1. Do not eat, drink or smoke 4 – 6 hours prior to test.
2. With approval from your physician, stop taking beta-blocker medications 24
hours prior to test.
EKG: No special preparation.
EXERCISE TREADMILL:
1. Do not eat, drink or smoke 4 – 6 hours prior to test.
2. Wear comfortable clothing/shoes to walk on treadmill.
3. With approval from your physician, stop taking beta-blocker medications 24
hours prior to test.
TRANSESOPHAGEAL ECHOCARDIOGRAM (TEE):
1. Do not eat, drink or smoke 4 – 6 hours prior to test.
2. No driving for 24 hours after test. Bring driver or arrange for transportation
home.
PULMONARY FUNCTION STUDIES:
1. Do not eat heavy meal before test.
2. Do not smoke for 4 – 6 hours.
3. Medication may be administered as part of this test.
EEG :
1. Wash your hair either the night before or the morning of the EEG.
2. Do not use hair gel, hair spray, grease or conditioners on hair.
3. Avoid caffeine products for 24 hours prior to test.
If you have a question regarding your medications, please contact your physician.
Your Appointment Date:_______________________ Time:____________
Please bring this physician order form with you on the day of your
appointment. Your procedure cannot be performed without a written
order from your doctor. The start of your procedure may be delayed if we
need to call your physician for another order to be faxed.
In preparation for your tests:
Please follow any fasting or procedure preparation instructions before coming
for your tests.
To save time, please call 678-474-7084 to pre-register or visit our website,
EmoryJohnsCreek.com to print and fill out registration forms prior to your
arrival. Please remember to bring with you at the time of registration the
following items:
All active insurance cards
Picture ID
Physician orders
Patients are responsible for all financial liabilities including co-payments,
deductibles, and out-of-pocket expenses at the time of registration or at the
time of discharge for emergency admissions. If the exact dollar amount has
not been determined, you will be asked to pay the estimated amount and will
be billed for the remainder.
We invite you to use our complimentary valet parking when you arrive.
Directions
From I-85: Take Pleasant Hill Road
exit. Travel west on Pleasant Hill for
5 miles until it becomes State Bridge
Rd. Turn right onto Medlock Bridge
Road (GA 141 N/Peachtree Pkwy).
Go 3.5 miles and turn left onto West
Johns Crossing. Hospital is less than
half a mile on the left.
From 400: Exit 10 (GA 120/Old
Milton Pkwy) - Merge onto GA 120 E
towards Duluth. Turn left onto
Kimball Bridge (GA 120E). Turn left
onto Jones Bridge Rd. Turn right
onto Sargent Road. Sargent Rd.
becomes McGinnis Ferry Rd. Turn
right onto West Johns Crossing.
Hospital is less than a quarter mile on
the right.
Address: 6325 West Johns Crossing, Johns Creek, GA 30097
Directions: 678-474-7090