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. See also the similar dataset MEDLINE PubMed Data Package.
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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 | - |