Patient Full Name:

DOB: (mm/dd/yyyy)

Primary Diagnosis:

ICD-10:

Ht:

Dosing Wt: (kg)

Administration Route:

CVCPICC LinePort-a-cath

SingleDoubleTriple

Macronutrient Daily Requirements:

 Dextrose (Carbohydrates):

Target: (g/kg/day)

Total Dextrose Required: (g)

 Amino Acids (Protein):

Target: (g/kg/day)

Total Amino Acids Required: (g)

 Lipids (Fat):

Target: (g/kg/day)

Total Lipids Required: (g)

Additional Notes:

Electrolytes Additives

Ordered Amount (Per Day)

Sodium Chloride (mEq)

Sodium Acetate (mEq)

 Sodium Phosphate (mEq)

Potassium Chloride (mEq)

Potassium Acetate (mEq)

Potassium Phosphate (mEq)

Magnesium Sulfate (mEq)

Calcium Gluconate (mEq)

 Other:

Micronutrients & Additional Additives

Multivitamins (MVI): 10 mL

Trace Elements: 1 mL

Thiamine 100 mg

Folic Acid 1mg

Insulin: units(if needed)

Doctor's Comments:

Final TPN Volume & Administration Details

Total Volume: (mL)

Infusion Rate: (mL/hr)

Duration: (hours)

Lab Order: CBC, CMP, LFT, TG, Magnesium, and Phosphorus every MWF initially, then weekly once stable.

Doctor's Comments

Prescriber Name:

Phone #:

Fax #:

Signature:

Prescriber NPI:

Date: