admission orders

Writing Admission OrdersWriting Admission OrdersThis item includes 4 components:p

• General comments about writing admission ordersorders

• A template for admission orders• Examples for each part of the templateExamples for each part of the template• An example of a complete set of orders

This is meant to be a guide but you will need a lot of practice and feedback to master this skillof practice and feedback to master this skill.

General CommentsOrder writing is complicated: ask for help, practice

it ftit oftenThe EMR complicates it a bit, but if you know how

t ‘ it ’ d ill b bl t fi t thto ‘write’ orders, you will be able to figure out the EMR

Do not rely on templates and order sets: they willDo not rely on templates and order sets: they will not always be available, and they may not be completecomplete

Order writing and patient management are inseparable. YOU MUST learn this if you want p yto be able to care for patients.

ADMISSION ORDERS TEMPLATE

One of the mnemonic devices that you can useOne of the mnemonic devices that you can use to help you remember the information to be included in all admission orders is the acronym:

ADA-Vitamin L

ADMISSION ORDERS TEMPLATEA: Admit to: (name of admitting doctor and unit)D: DiagnosisA: AllergiesA: Allergies

V: Vital Signs( f)I : Ins (diet, ivf)

T: Telemetry or other monitoring A: ActivityyM: Meds I: Is and OsN: NursingN: Nursing

L: Labs

ADMISSION ORDERS TEMPLATEA: Admit to: (name of admitting doctor and unit)unit)

ADMISSION ORDERS TEMPLATEA: Admit to: (name of admitting doctor and unit)unit)

E lExamples:

Admit to ICU, Dr. CrandallAdmit to 4N, Dr. Schindler

ADMISSION ORDERS TEMPLATEA: Admit to: (name of admitting doctor and unit)

D: DiagnosisD: Diagnosis

ADMISSION ORDERS TEMPLATEA: Admit to: (name of admitting doctor and unit)

D: Diagnosis ExamplesD: Diagnosis- Examples

Abdominal PainAbdominal PainS/P appendectomy

ADMISSION ORDERS TEMPLATEA: Admit to: (name of admitting doctor and unit)D: Diagnosis

A: Allergies

ADMISSION ORDERS TEMPLATEA: Admit to: (name of admitting doctor and unit)D: Diagnosis

A: AllergiesExamples:p

NKDA (No known drug allergies)Allergies: Sulfa drugs IV contrastAllergies: Sulfa drugs, IV contrast

ADMISSION ORDERS TEMPLATEA: Admit to: (name of admitting doctor and unit)D: DiagnosisA: Allergies

V: Vital Signs


V: Vital Signs- Vital signs q one hour (in ICU)

“VS” typically includes temperature, blood pressure, heart rate and respiratory rate. If you want any additional vital signs they should bewant any additional vital signs, they should be ordered specifically

Example:Example:Monitor CVP q one hourMonitor pulse ox q 4 hours


V: Vital Signs

I : Ins (diet, ivf)


V: Vital Signs

I : Ins (diet, ivf)All patients should have a diet orderAll patients should have a diet order

Examples: NPONPOGeneral Diet1800 l ADA di1800 cal ADA dietClear liquids


V: Vital Signs

I : Ins (diet, ivf)- Maintenance IVFIVF should be ordered if neededIVF should be ordered if neededAll IVF orders need the type of fluid, any additives, and the rate. Examples:, pD5.45NS with 20 KCl at 100cc per hourLR at 85 cc per hourp.9NS at TKO (to keep open rate)Heplock IV (this means the IV is capped off and no fluids)


V: Vital Signs

I : Ins (diet, ivf)- Maintenance IVF

This is also an appropriate area to order bl d d if d d f lblood products if needed, for example:Transfuse one unit PRBC over 2 hours


V: Vital Signs

I : Ins (diet, ivf)- Maintenance IVFType of fluidType of fluidTypical is D5.45 with 20KCl

Consider changing if diabetic, renal failure, electrolyte abnormalities, etc.

Also consider alternative fluids (colloid, blood, LR) if resuscitation or replacement is needed in addition to maintenance


V: Vital Signs

I : Ins (diet, ivf)- Maintenance IVFRateRate

– Formula for maintenance rate:– First 10 K: 4cc/K/hours 0 cc/ / ou– Second 10 K: 2cc/K/hour– Remaining K: 1cc/K/hour– Example: 70K person: 40 + 20 + 50 = 110cc/hour


V: Vital SignsI : Ins (diet, ivf)

T T l t th it iT: Telemetry or other monitoring


V: Vital SignsI : Ins (diet, ivf)

T T l t th it iT: Telemetry or other monitoring

Order telemetry if needed.

Any other invasive monitoring: a-line, CVP, pulse ox, swan ganz

ADMISSION ORDERS TEMPLATEA: Admit to: (name of admitting doctor and unit)D: DiagnosisA: Allergiesg

V: Vital SignsI : Ins (diet, ivf)T: Telemetry or other monitoringT: Telemetry or other monitoring

A: Activity

ADMISSION ORDERS TEMPLATEA: Admit to: (name of admitting doctor and unit)D: DiagnosisA: Allergiesg

V: Vital SignsI : Ins (diet, ivf)T: Telemetry or other monitoringT: Telemetry or other monitoring

A: ActivityExamples:Examples:

As toleratedbed restno weight bearing to right footambulate with assist only


V: Vital SignsI : Ins (diet, ivf)T: Telemetry or other monitoring A: Activity

M: Meds


V: Vital SignsI : Ins (diet, ivf)T: Telemetry or other monitoring A: Activity

M: MedsFor every patient consider the following categories and y p g gif they are indicated for your patient (not all are needed in all patients):

Pain medsAntibioticsDVT prophylaxis (may not be a med)Ulcer prophylaxisP i dPrevious meds


A: Admit to: (name of admitting doctor and unit) D: DiagnosisD: DiagnosisA: Allergies

V: Vital SignsI : Ins (diet, ivf)T: Telemetry or other monitoringT: Telemetry or other monitoring A: ActivityM: Meds

I: Is and Outs


A: Admit to: (name of admitting doctor and unit) D: DiagnosisD: DiagnosisA: Allergies

V: Vital SignsI : Ins (diet, ivf)T: Telemetry or other monitoringT: Telemetry or other monitoring A: ActivityM: Meds

I: Is and OutsFor most patients strict Is and OsConsider how frequently you want UO checked:

• UO q one hour (typical for ICU pt with foley)• UO q shift

ADMISSION ORDERS TEMPLATEA: Admit to: (name of admitting doctor and unit) D: DiagnosisA: Allergies

V: Vital SignsI : Ins (diet, ivf)T: Telemetry or other monitoring A: ActivityM: Meds I: Is and Outs

N: Nursing


V: Vital SignsI : Ins (diet, ivf)T: Telemetry or other monitoring A: ActivityM: Meds I: Is and Outs

N: Nursing - Can include many things. Examples:

Call HO for BP>170/90 <90/60 HR>120<60 RR>30<12 T>38Call HO for BP>170/90, <90/60, HR>120<60, RR>30<12, T>38, UO<30cc/hour or 200/shift, Glucose >200<70

Dressing changes: wet to dry to right leg wound tidKeep leg elevatedCall HO for any change in mental statusCheck and record pedal dopplers q 4 hoursJP to bulb suctionF l t itFoley to gravityIncentive spirometer q one hour while awakeTeds and boots at all times unless ambulating


V Vit l SiV: Vital SignsI : Ins (diet, ivf)T: Telemetry or other monitoring A: ActivityM: Meds I: Is and OutsI: Is and Outs

N: Nursing

L: Labs

Orders must include the specific test, when you want it done and how often if it is to bewant it done, and how often if it is to be repeated. Avoid open ended orders that have no stop date (such as cbc q d).p ( q )



N: Nursing

L: Labs

It is not adequate to order “electrolytes”



N: Nursing

L: LabsBe aware that in the EMR you may be asked to link orders to a specific diagnosis or indication

Example: venous duplex, diagnosis: edema



N: Nursing

L: Labs Examples of correctly written labs:CBC d i AMCBC now and in AMChem 7 (names are different at different institutions) q am for 3 daysChem sticks ac and hs q dCXR stat Venous duplex right leg todayp g g y


V: Vital SignsV: Vital SignsI : Ins (diet, ivf)T: Telemetry or other monitoring A: ActivityA: ActivityM: Meds I: Is and OsN: Nursing

L: LabsL: Labs

Example of a complete set of Orders

• Admit to 4NS: Dr. Schindler • Activity as toleratedM d• Dx: S/P carotid

endarterectomy• NKDA

• Meds:– ASA 325mg PO q d– Atenolol 50mg po q d– Tylenol 650 po q 4 hours prn

• Vital signs q 4hours, please include neuro checks and check incision for hematoma

• Ins: Clear liquid diet

Tylenol 650 po q 4 hours prn pain

– Kefzol 1g q 8 hours x 2 doses• Strict Is and Os

N i• Ins: Clear liquid diet• 45NS with 20KCl at 85cc/hour

until tolerating PO then heplock

• Nursing:– Teds and boots at all times

unless walking– Call HO for BP>170/90,

90/60 HR 120 60heplock• Telemetry not needed

<90/60, HR>120<60, RR>30<12, T>38, UO<30cc/hour or 200/shift, Glucose >200<70

L b• Labs:– Chem stick ac and hs

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