Healthcare Lorazepam Order

HEALTHCARE LORAZEPAM ORDER

This form documents a clinician order authorizing administration of lorazepam (a Schedule IV benzodiazepine) to the patient named below. The prescriber attests that the medication is clinically indicated, that risks and alternatives have been discussed with the patient or authorized representative, and that administration will comply with applicable law and institutional policy.

Patient Information

Patient Name:    MRN/ID:

Date of Birth:    Gender: Male Female Other

Insurance / Billing (if applicable)

Medical History & Safety

Prior Surgeries / Anesthesia Issues:

Pregnancy Status: Pregnant Not pregnant Unknown

Order: Lorazepam (Medication Details)

Medication: Lorazepam — Generic name recorded for administration.

Strength (mg):    Formulation:

Route (select all that apply): PO IV IM Sublingual

Frequency (select one): Single dose Scheduled: PRN for:

PRN parameters (if applicable): Minimum interval between doses (hours):    Maximum total dose in 24 hours (mg):

Dose escalation permitted: Yes    If yes, parameters:

Quantity / Units (for dispensing):    Refills:

Substitution permitted: Yes    No

Start Date:    Anticipated Stop/Review Date:    Authorization Expiration Date:

Monitoring, Precautions & Contraindications

Contraindications reviewed (select as applicable):
Known severe respiratory insufficiency Allergy to benzodiazepines Acute intoxication with alcohol or other CNS depressants

Required monitoring during and after administration:

Prescriber has reviewed potential interactions with current medications and assessed respiratory and neurologic risk: Yes No

Risks, Alternatives & Patient Counseling

The patient has been informed of the risks associated with lorazepam, including sedation, cognitive impairment, respiratory depression (particularly if combined with opioids or alcohol), tolerance, dependence, and withdrawal. Alternatives and non-pharmacologic options have been discussed where appropriate. The patient has been instructed not to operate vehicles or heavy machinery while sedated and to avoid alcohol and other CNS depressants.

Patient / Representative acknowledges counseling and understanding of risks: Acknowledged

Sedation and impaired coordination Risk of dependence and withdrawal Interactions with alcohol/opioids Safe storage and disposal

Prescriber Attestation

I, the undersigned prescriber, certify that the above order is medically indicated, that I have reviewed the patient's history, allergies, and current medications, and that I will provide or arrange appropriate monitoring and follow-up.

Date of Order:    Time:

Privacy & Authorization

By signing below, the patient or authorized representative acknowledges receipt of counseling regarding lorazepam, consents to administration per this order, and authorizes the release of relevant medical information for treatment and billing purposes as required for care coordination.

HIPAA Privacy Acknowledgment: Patient has received or been offered facility privacy practices.

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