Others titles
- Nursing Admission Orders
- Nursing Inpatient Admission Order Sets
Keywords
- Hospital Admission
- Inpatient Care
- Nursing Order Sets
- Patient Care Plan
- Admission Orders
- Discharge Plan
Standardized Hospital Admission Orders

This dataset consists of 29 standardized hospital admission orders. These admission orders are developed by the family medicine department of the Scott & White Clinic at College Station, Texas. These orders are updated every two years.
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Description
The purpose of the Standardized Admission Orders is to reduce variability, simplify work processes and improve the quality of patient care services, especially for family physicians because the scope of their specialty is vast. During a typical day, it is normal for them to encounter a wide variety of patient problems, and nowhere is it as difficult – or important – for them to strive for consistency, efficiency and accuracy in patient care as in the hospital setting.
When standardized admission orders were first developed seven years ago, there were 27 conditions that were thought to be most useful. There are currently 29 admission orders that cover the conditions that the family physicians most frequently encounter in the hospital. It has been observed that this order set covers more than 90 percent of hospital admissions. These order sets are updated every two years.
The admission orders cover the following conditions: Acute Mental Status Change, Acute Myocardial Infarction, Acute Pancreatitis, ASA Overdose, Asthma, Chest Pain, Childhood Bacterial Meningitis, Community Acquired Pneumonia, Congestive Heart Failure, Croup, CVA, Diabetic Ketoacidosis, DVT Lovenox Therapy, DVT Discharge, Endometritis, HIV Pneumonia, Hyperkalemia, Hypernatremia, Hypokalemia, Hyponatremia, Lower GI Bleed, Intractable Headache, Neutropenic Fever, Partial Small Bowel Obstruction, Pediatric Vomiting-Diarrhea-Dehydration, Pelvic Inflammatory Disease, Pyelonephritis, Seizures, Upper GI Bleed
About this Dataset
Data Info
Date Created | 2001-10-01 |
---|---|
Last Modified | 2006-09-13 |
Version | 2006-09-13 |
Update Frequency |
Biennial |
Temporal Coverage |
N/A |
Spatial Coverage |
United States |
Source | John Snow Labs; American Academy of Family Physicians, Family Medicine Department of the Scott & White Clinic at College Station Texas; |
Source License URL | |
Source License Requirements |
N/A |
Source Citation |
N/A |
Keywords | Hospital Admission, Inpatient Care, Nursing Order Sets, Patient Care Plan, Admission Orders, Discharge Plan |
Other Titles | Nursing Admission Orders, Nursing Inpatient Admission Order Sets |
Data Fields
Name | Description | Type | Constraints |
---|---|---|---|
Admission_Order_Name | Name of admission order | string | required : 1 |
Patient_Name | Name of the patient | string | - |
Patient_Age | Patient's age | string | - |
Patient_Date_of_Birth | patient's date of birth | string | - |
Medical_Record_Number | Medical record number | string | - |
Status | Status of admission. "____" specifies that a value needs to be filled by physicians/nurses in these blanks. | string | required : 1 |
Attending_Doctor_Name | Name of attending physician | string | - |
Attending_Doctor_Phone | Phone number of attending physician | string | - |
Admitting_Diagnosis | Diagnosis at the time of admission. "____" specifies that a value needs to be filled by physicians/nurses in these blanks. | string | required : 1 |
ICD_10_CM_Codes | ICD-10-CM codes for Admitting_Diagnosis | string | required : 1 |
ICD_10_CM_Codes_Description | Description of ICD-10-CM codes for Admitting_Diagnosis | string | required : 1 |
Associated_or_Contributing_Diagnosis | Associated/accompanying diagnoses | string | - |
Patient_Condition | Condition of patient at the time of admission | string | required : 1 |
Code_Status | Value: Full Code, DNR (Do-Not-Resuscitate order) | string | - |
Allergies | Allergies, if any | string | - |
Diet | Recommended diet. "____" specifies that a value needs to be filled by physicians/nurses in these blanks. | string | - |
Activity | Ativity restrcition, if any | string | - |
Nursing_Responsibilities | Nursing Orders. "____" specifies that a value needs to be filled by physicians/nurses in these blanks. | string | - |
Medications | List of Medications prescribed for the treatment. "____" specifies that a value needs to be filled by physicians/nurses in these blanks. | string | - |
IV_Administration | IV given for the treatment. "____" specifies that a value needs to be filled by physicians/nurses in these blanks. | string | - |
Laboratory_Tests | Lab tests performed. "____" specifies that a value needs to be filled by physicians/nurses in these blanks. | string | - |
Radiology_Procedures | Radiology procedures performed | string | - |
Nursing_Considerations | Medications or tests to consider, if any | string | - |
Diagnostic_Studies | Diagnostic studies done on patient's condition | string | - |
Decision | Decision made, as part of patient care plan | string | - |
Consult | Consultation recommended to patient | string | - |
Patient_Education | Patient education | string | - |
Follow_Up | Follow-up plans, if any. "____" specifies that a value needs to be filled by physicians/nurses in these blanks. | string | - |
Immunizations | Decision related to immunization | string | - |
Other_Orders | Miscellaneous orders, if any | string | - |
Date_And_Time | Date and time of visit. | string | - |
Data Preview
Admission_Order_Name | Patient_Name | Patient_Age | Patient_Date_of_Birth | Medical_Record_Number | Status | Attending_Doctor_Name | Attending_Doctor_Phone | Admitting_Diagnosis | ICD_10_CM_Codes | ICD_10_CM_Codes_Description | Associated_or_Contributing_Diagnosis | Patient_Condition | Code_Status | Allergies | Diet | Activity | Nursing_Responsibilities | Medications | IV_Administration | Laboratory_Tests | Radiology_Procedures | Nursing_Considerations | Diagnostic_Studies | Decision | Consult | Patient_Education | Follow_Up | Immunizations | Other_Orders | Date_And_Time |
Intractable Headache | 23 hr observation | Intractable Headache | G43.911 | Migraine, unspecified, intractable, with status migrainosus | Stable; Fair; Serious; Critical | Regular; but no caffeine | Notify MD for: T > 100, P < 60 or > 120, BP < 90/60 or > 170/110 | No analgesics; No narcotics; Reglan 10 mg IV followed by DHE 0.5 mg IV; Then every 8 hrs give Reglan 10 mg IV followed by DHE 1 mg IV until patient is 100% HA free X 24-48 hrs (HA scores = 0); Other: _____ | Heplock | Hemogram, basal metabolic profile | ||||||||||||||||||||
Hypernatremia | Observation; Admission; Monitored bed; ICU | Hypernatremia | E87.0 | Hyperosmolality and hypernatremia | Stable; Fair; Serious; Critical | Bed rest and up in chair as tolerated | Notify MD for T > 101, BP > 190/100 or < 90/60, neuro changes | Hypovolemic: _____ normal saline IV @ 500 mL/hr until orthostasis resolves, then Dextrose 5% in water (if hyperosmolar) or Dextrose 5% in 1/2 normal saline (if not Hyperosmolar) IV @_____ mL/hr; Hypervolemic: Lasix 80 mg IV/PO daily; Dextrose 5% in water @ ______ mL/hr | Comp met profile; UA ; Urine NA; TSH; Urine OSM | |||||||||||||||||||||
ASA Overdose | Observation; Admission; Medical floor; Monitored bed; Other | ASA overdose | T39.014 | Poisoning by aspirin, undetermined, initial encounter | Stable; Fair; Serious; Critical | Full Code; DNR | NPO; Clear Liquid; AHA step 2; ADA; Other | Bed rest with bathroom privileges | Vital signs every 4 hrs for 24 hrs then every 4 hrs if stable; Suicide precautions; Gastric lavage in ER with activated charcoal; Consider dialysis if serum salicylate greater than 70 mg/dl | Vitamin K 10 mg IM now; Guaiac all stools; Other | Dextrose 5% in 1/2 normal saline with 44 mEq bicarbonate/L @ 300 mL/hr (forced alkaline diuresis) | ABGs; Hemogram; Lytes; Glucose; Salicylate level, if not done in ER | Psych; Social services; MHMR | |||||||||||||||||
Lower Gi Bleed | Medical; Telemetry; ICU | Lower GI Bleed | K92.2 | Gastrointestinal hemorrhage | Stable; Fair; Serious; Critical | NPO except meds; Other | Bed rest with bedside commode; Bathroom privileges with assistance | ICU: per routine; Medical: every 1 hr until stable X4, then every 2 hrs until stable X4, then every 4 hrs; Notify MD for: BP < 90/60 or > 180/110, P < 60 or > 120, urine output < 30 cc/hr over 4 hrs, all H/H results | Bolus normal saline _____cc over _____; Dextrose 5% normal saline with 20 mEq KCl/L @ _____mL/hr total | Hemogram, comp met profile, PT/PTT/INR on admission; HH every 6 hrs X24 hrs; Type and screen for _____units PRBC | Have patient sign informed consent form for blood transfusion. | |||||||||||||||||||
Upper GI Bleed | Observation; Admission; Medical Floor; Telemetry; ICU | Upper GI Bleed | K92.2 | Gastrointestinal hemorrhage | Stable; Fair; Serious; Critical | NPO except meds, NPO including meds | Bed rest with bedside commode; Bathroom privileges with assistance | ICU: per routine; Telemetry or medical: every 1 hr until stable X4, then every 2 hrs until stable X4, then every 4 hrs; Notify MD for: BP < 90/60 or > 170/110, P < 60 or > 120, Urine output < 30 cc/hr over 4 hrs, all H/H results; If NG to suction, replace NG fluid cc for cc with NG with 20 mEq KCl every 12 hrs | Protonix 40 mg PO/IV every 12 hrs; Other: ___ | Bolus normal saline _____cc over ______; Dextrose 5% normal saline with 20mEq KCl/l @ _____mL/hr total | Hemogram, comp met profile, PT/PTT/INR on admission; HH every 4 hrs X3; Type and screen for _____units PRBC | |||||||||||||||||||
Pediatric Vomiting/Diarrhea/Dehydration | Pediatric Floor: Observation; Admission | Pediatric vomiting/diarrhea/dehydration | R11.10; R19.7; E86.0 | Vomiting unspecified; Diarrhea unspecified; Dehydration | Stable; Fair; Serious; Critical | NPO; Formula/Breast; Age appropriate diet as tolerated | Crib; Bassinet; Bed | Vital signs: every 4 hrs | Tylenol (10 mg/kg) _____ PO/PR every 4 hrs prn T > 101; Phenergan 12.5-25 mg PR 1 6-8 hrs prn n/v | Replacement (mls) = % X wt (kg): Replacement 1/3 over first 4 hrs with Dextrose 5% in 1/2 normal saline; Replacement 1/3 over second 8 hrs with Dextrose 5% in 1/2 or 1/4 normal saline; Replacement 1/3 over third 12 hrs with D5.2 normal saline; Replace in addition to maintenance | Basal metabolic profile, CBC UA on admission; basal metabolic profile in a.m.; Stool for rotazyme, routine culture, O&P, yersinia | |||||||||||||||||||
Partial Small Bowel Obstruction | Surgical; Medical Floor; Observation; Admission | Partial Small Bowel Obstruction | K56.60 | Unspecified intestinal obstruction | Stable; Fair; Serious; Critical | NPO | Bed rest with bathroom privileges with assistance | Vital signs: every 4 hrs for 24 hrs then every shift; Notify MD for: T > 101.5, P > 120, BP < 90/60 or > 180/110; NG tube to low continuous suction; I&O | Demerol 25-50 mg slow IVP every 3-4 hrs prn pain; Phenergan 12.5 mg slow IVP every 3-4 hrs | Dextrose 5% normal saline with 20 mEq KCl @ 125 mL/hr; Bolus _____; Replace NG output mL per mL with ______ normal saline every 12 hrs | Daily hemogram, basal metabolic profile in a.m. | X-ray: acute abdominal series if not done in ER/clinic | Surgical consult as indicated (complete obstruction); Consider DVT prophylaxis with Lovenox 40 mg sq daily; Consider gastrografin UGI with small bowel follow-through after 24-26 hrs of NG suction | |||||||||||||||||
Hyponatremia | Observation; Admission; Medical bed; Telemetry; ICU | Hyponatremia | E87.1 | Hypo-osmolality and hyponatremia | Stable; Fair; Serious; Critical | Full Code; DNR | NPO; Clear liquid; AHA step 2; ADA ______ calories; Other | Bed rest with bathroom privileges with assistance | Orthostatic VS every 4 hrs until stable x4, then every shift; Notify MD for: T > 101, BP < 90/60 or > 190/100, neuro changes | Hypovolemic: ______ normal saline IV @ 500 mL/hr until orthostasis resolves, then; Dextrose 5% normal saline (if hyperosmolar) at ______ mL/hr, OR; Dextrose 5% in 1/2 normal saline (if not hyperosmolar) at _____ mL/hr; Hypervolemic: Lasix 80 mg IV/PO daily; Dextrose 5% in water at _____mL/hr | CMP, UA, urine Na+, TSH, urine OSM, plasma osmolality and CXR on arrival daily BMP | DVT prophylaxis with Lovenox 40 mg SQ daily; D/C medications that could contribute to hyponatremia (i.e., diuretics, Tegretol, SSRI, amiodarone, theophylline) | ||||||||||||||||||
Pyelonephritis | Observation; Admission; Medical Floor; Monitored bed; Other | Pyelonephritis | N10 | Acute pyelonephritis | Stable; Fair; Serious; Critical | Full Code; DNR | NPO; Clear liquid; AHA step 2; ADA ______ calories; Other | Bed rest with beside commode; Bathroom privileges; Up ad lib | Vital signs every 4 hrs for 24 hrs then every shift; Notify MD for: T > 101.5, P > 120, BP < 90/60 or > 180/110; Daily weight; I&O | Levaquin 500 mg IV every 24 hrs; Tylenol 650 mg PO every 4 hrs prn temp > 100/pain; Phenergan 25 mg IV/IM every 4 hrs prn nausea; Demerol 50 mg IM every 4 hrs prn pain; If toxic: consider adding Gentamycin (7mg/kg/day) IVP; adjust for renal dose if indicated | Dextrose 5% in 1/2 normal saline @ 100 mL/hr; Other _____ | Admission: blood cultures x2 prior to antibiotics, CBC, UA, urine culture, basal metabolic profile; Daily: CBC | If history of stones or recurrent pyelo consider IVP or renal ultrasound; DVT prophylaxis with Lovenox 40 mg sc daily | |||||||||||||||||
Seizure Disorder | Observation; Admission; Medical Floor; Telemetry; ICU | Seizure Disorder | G40.89 | Other seizures | Stable; Fair; Serious; Critical | Bed rest with seizure precautions | Vital signs: every 2 hrs with neuro checks until stable X4, then every 4 hrs; Notify MD for: T > 100, BP < 90/60 or > 170/110, seizures, Glasgow coma scale < 15 | Dilantin loading options:; PO Dilantin _____mg (15 mg/kg) every 4 hrs X3 doses, OR; IV Dilantin 50 mg/min; IVP to total of _____mg (18 mg/kg) then begin Dilantin 300 mg PO daily, OR; Fosphenytoin-load (10-20 PE/kg); Ativan 2-4 mg slow IVP over 10 min prn active seizures lasting more than 3 min; Tylenol 650 mg PO every 4-6 hrs prn fever or pain; MOM 30 mL PO every 12 hrs prn constipation; Other ______ | Hemogram; Comp met profile; VDRL; Urine Toxicology screen for “drugs of abuse” | MRI of head with and without contrast for “new onset seizures, R/O mass, lesion”; EEG for “new onset seizures” to be read by neurologist |