HOME PHOTOTHERAPY PHYSICIAN ORDER FORM

Statement of Medical Necessity (SMN)
Patient & Clinical Data

Infant Name:______________________________________DOB/Time:___________________

Gestational Age:___________________ Blood Type __________ Coombs_____

TSB (Total Serum Bilirubin) Level:_______mg/dL.Age of Baby in hours_____

Date/Time of Lab:__________________________________________________

AAP Threshold: Is the TSB within 2 mg/dL of the treatment line? [ ] Yes [ ] No

Risk Factor Screening (The "No" List)

• [ ] No signs of sepsis or acidosis.

• [ ] No known isoimmune hemolytic disease (DAT/Coombs negative).

• [ ] The infant is feeding, voiding, and stooling normally.

The Prescription

• Equipment: LED-based Home Phototherapy System 

• Duration: Typically 1–4 days (until TSB falls below discharge threshold).

• Frequency: Continuous (except for feeding/diaper changes).

• Monitoring: Repeat TSB lab ordered for tomorrow morning  

  (Date: ___________Time:________).  Then again (Date:___________Time:_________

• Discontinuation Criteria: * Stop when TSB is  ______ mg/dL.

Note: Standard practice is usually 2–3 mg/dL below the start threshold.

Physician Signature     ___________________________

Printed Name: _______________________________ Date: _____________Time______

Office Phone: ______________________ Direct Fax: ______________________