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 |
| Acute Mental Status Change | Observation; Admission; Medical floor; Monitored bed; Other | Acute Mental Status Change | R41.82 | Altered mental status, unspecified | Stable; Fair; Serious; Critical | Full Code; DNR | NPO; Clear Liquid; AHA step 2; ADA; Other | Bed rest with bedside commode; Bathroom privileges; Up ad lib; Fall precautions | Vital signs with neuro every 4 hrs for 24 hrs then every shift; Notify MD for: T > 101.5, HR > 120, BP < 90/60 or > 180/110, decline in neurostatus, O2 sat < 92%; Pulse ox every 8 hrs nasal cannula/face mask to maintain O2 sat > 92%; I&O | Acutely agitated and over 200 lbs without renal/hepatic impairment: Haldol 10 mg PO/IM, Ativan 4 mg PO/IM and Cogentin 1 mg PO/IM every 6 hrs prn; hold if BP < 100/60 mmHg; Acutely agitated and over 200 lbs without renal/hepatic impairment: Geodon 20 mg IM every 8 hrs prn; hold if BP < 100/60 mmHg; Acutely/moderately agitated and under 200 lbs without renal/hepatic impairment: Risperdal 2 mg and Ativan 2 mg PO every 6 hrs prn; Acutely/moderately agitated and under 200 lbs without renal/hepatic impairment: Haldol 5 mg IM and Ativan 2 mg IM and Cogentin 1 mg IM every 4 hrs prn; hold if BP < 100/60 mmHg; Acutely/moderately agitated and under 200 lbs without renal/hepatic impairment: Geodon 20 mg IM every 8 hrs prn; hold if BP < 100/60 mmHg; Mildly agitated with renal/hepatic impairment: Risperdal 2 mg PO and Ativan 2 mg PO every 8 hrs prn; Elderly/Frail: Risperdal 0.5 mg PO and Ativan 0.5 mg PO every 8 hrs prn (not to exceed 3 in 24 hrs); Elderly/Frail: Haldol 2 mg IM and Ativan 1 mg every 8 hrs prn; hold if BP < 100/60 mmHg | IV lock, flush per routine; IV ___@ mL/hr | Admission: CBC, sed rate, comp met profile, serum ammonia, HIV, RPR, TSH, urine drug screen; Consider: serum for lead and heavy metals and lumbar puncture; Other labs, if any | CT head without contrast; CXR 2 view, reason: rule out bony abnormality/infiltrate; Consider carotid Doppler | |||||||||||||||||
| 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 | |||||||||||||||||
| Asthma | Observation; Admission; Medical floor; Monitored bed; Other | Asthma Exacerbation | J45.901 | Unspecified asthma with (acute) exacerbation | Stable; Fair; Serious; Critical | Full Code; DNR | NPO; Clear Liquid; AHA step 2; ADA; Other | Bed rest with bedside commode; Bathroom privileges; Up ad lib | Vital signs every 4 hrs for 24 hrs then every shift; Notify MD for: T > 101.5, HR > 120, BP < 90/60 or > 180/110, Pulse ox < 90%, decrease level of consciousness or respiratory distress; I&O | Albuterol nebulizer every ______ hrs and prn; Methylprednisone 125 mg IV bolus now, then 80 mg IVP every 8 hrs; Tylenol 500 mg 2 tabs PO every 4 hrs prn temp > 101 or pain; Ambien 10 mg PO at bedtime prn insomnia | IV lock, flush per routine; IV ___@ mL/hr | Admission: hemogram, basal metabolic profile; ABG if pulse ox < 90% or if severe respiratory distress or decreased LOC develops | CXR on admission; Pulse ox upon arrival to floor and with neb treatments; Peak flow measurement pre and post neb treatments | |||||||||||||||||
| Acute Myocardial Infarction | Observation; Admission; Medical floor; Monitored bed; Other | Acute Myocardial Infarction | I21.3 | ST elevation (STEMI) myocardial infarction of unspecified site | Stable; Fair; Serious; Critical | NPO meds; AHA step 1; Other | Bed rest with bedside commode; Complete bed rest | Vital signs: per routine; O2 @ 2, 4, 6 L/min via nasal cannula; 12 lead ECG: stat (if not done in ER) and every morning; Portable CXR if not done in ER; 2 D Echo with Doppler flow to be read by _____; Continuous cardiac monitoring; Arrhythmia protocol | Clopidogrel 300 mg PO now, then 75 mg PO daily; ASA 81 mg, 4 PO now (if not given in ER); ECASA 325 mg PO daily; Lovenox _____mg (1 mg/kg) every 12 hrs-start now; Nitropaste _____in (es) every _____hrs; Zocor _____mg PO with evening meal; NTG 0.4 mg SL every 5 min prn chest pain X3 doses; Beta blocker: Metoprolol 12.5 mg PO now and then _____mg every 12 hrs; ACE: Captopril 6.25 mg PO now and then 12.5 mg PO in every 8 hrs (hold for SBP < 105 or patient going to cath lab) | Hemogram; CK; CK-MB; Troponin I; Comp met profile; if not done in ER; MG; Fasting lipid panel; Repeat CK, CK-MB, Troponin I @ ______ (8 hrs) and _____(16 hrs) | NTG drip (50 mg in 250 mL D5W), start at 3 mcg/min and titrate to relieve chest pain and maintain SBP < 130 and > 90 ; Integrilin 180 mcg/kg IV bolus (_____mcg total) over 1-2 min then IV infusion @ 2 mcg/kg/min, not to exceed 72 hrs, while on infusion, obtain hemogram, creat every 8 hrs-if platelets < 1,000,000 call MD; If creatinine level 2-4 decrease by half, if creatinine > 4 discontinue infusion and call MD; Tylenol 650 mg every 4-6 hrs prn pain/fever; Ambien 5 mg @ bedtime prn insomnia; MOM 15-30 mL PO every 12 hrs prn constipation | |||||||||||||||||||
| Chest Pain | Observation; Admission; Medical floor; Monitored bed; Other | Chest pain; R/O acute coronary syndrome | R07.9 | Chest pain, unspecified | Stable; Fair; Serious; Critical | Full Code; DNR | NPO; Clear liquid; AHA step 2; ADA ______ calories; Other | Bed rest with bedside commode; Bathroom privileges; Up ad lib | Vital signs every 1 hr for 4 hrs then every 4 hrs; Notify MD for: T > 101.5, P > 120, BP < 90/60 or > 180/110, abnormal lab results; Weight on arrival; Continuous cardiac monitoring; arrhythmia Orders; Stat ECG for significant chest pain; O2 at 2 L nasal cannula; notify MD if Pulse ox < 93% | Nitropaste 0.5 inch topically every 8 hrs; Enteric coated aspirin 325 mg PO now and every morning; NTG 1/150 SL prn CP, may repeat 15 min until pain free or max three tabs per episode; Morphine sulfate 5 mg slow IVP every 30 min prn severe chest pain; Tylenol 500 mg 2 PO every 4 hrs prn headache/fever/pain; Ambien 10 mg PO at bedtime prn for insomnia; MOM 30 mL PO BID prn for constipation; Maalox 30 mL PO every 4 hrs prn for indigestion | IV lock, flush per routine; IV ___@ mL/hr | Admission: CBC, basal metabolic profile, TSH, Troponin I every 8 hrs x2; Lipid profile in a.m. | CXR if not done; ECG every morning; Cardiolite stress test; Adenosine cardiolite stress test; Echocardiogram â to be read by ______ | |||||||||||||||||
| Congestive Heart Failure | Observation; Admission; Medical floor; Monitored bed; Other | Congestive Heart Failure | I50.9 | Heart failure, unspecified | Stable; Fair; Serious; Critical | Full Code; DNR | NPO; Clear liquid; AHA step 2; ADA ______ calories; Fluid restriction: 2000 mL/24 hrs or ______mL/24 hrs | Bed rest; Bed rest with bathroom privileges; Up with assistance; Other | Vital signs every 4 hrs or per unit routine; Notify MD for: increasing dyspnea; chest pain; BP < 90/60 or > 180/110; P < 60 or > 120; Daily weights; Strict I&O; O2 via NP @ 2, 3 or 4 L/min; Pulse ox check every 4 hrs and titrate O2 to keep pulse ox > 92%; Continuous cardiac monitoring | ASA _____mg PO every morning; Clopidogrel 75 mg PO every morning; ACE inhibitor: _____; Lasix ______mg IVP every _____hrs; NTG paste _____ inch(es) every _____ hrs; Betablocker:_____; Digoxin (NYHA class III/IV): _____ mg PO daily; Spironolactone ______mg PO bid; Tylenol 650 mg PO every 4-6 hrs prn pain; MOM 30 mL PO every 12 hrs prn constipation; Ambien 10 mg PO at bedtime prn for insomnia | IV lock, flush per routine | CBC, BNP, CK, CK-MB, Troponin I, MG+, TSH, UA on admission; Repeat CK, CK-MB, Troponin I in 8 hrs; Daily basal metabolic profile; Other ______ | Echocardiogram-to be read by _____; EKG if not done in ER; CXR: _____ Portable _____PA/Lat, Reason: CHF | Begin CHF patient education | ||||||||||||||||
| Childhood Bacterial Meningitis | ICU; Pediatrics | Childhood Bacterial Meningitis | G00.9 | Bacterial meningitis, unspecified | Stable; Fair; Serious; Critical | NPO; Age appropriate diet | Routine for age; Crib; Bassinet; Bed rest | Vital signs with BP: every _____hrs; Neuro vitals: every _____hrs | < 1 month of age: ampicillin 50 mg/kg/dose IVPB every 8 hrs; gentamicin 2.5 mg/kg/dose IVPB every 12 hrs; Age 1-3 months: ampicillin (50 mg/kg) ______mg IVPB every 8 hrs; cefotaxime (50 mg/kg) ______mg IVPB every 6 hrs; > 3 months: cefotaxime (50 mg/kg) ______mg IVPB every 6 hrs; Other: _____ | Normal saline @ ______mL/hr with 5 mEq KCl/250 mL should be 2/3 maintenance; Maintenance: 100 mL/kg/day up to 10 kg plus 50 mL/kg/day for each kg between 10-20 plus 20 mL/kg/day for each kg > 20 kg | Send CSF for: tube 1: C&S, gram stain on centrifuge spun specimen; tube 2: glucose, protein; tube 3: cell count and diff; tube 4: hold; Blood cultures X2, CBC, basal metabolic profile; UA, Urine C&S; If concerned about SIADH: serum Lytes every 8 hrs, urine Lytes with Osm every day, urine SG every shift | |||||||||||||||||||
| Community Acquired Pneumonia | Medical; ICU | Pneumonia | J15.9 | Unspecified bacterial pneumonia | Stable; Fair; Serious; Critical | Regular as tolerated | Bed rest with bathroom privileges with assistance | Vital signs: every 4 hrs; Spot pulse ox on room air upon arrival; ABG if Pulse ox < 90% or severe respiratory distress; Call MD for BP < 90/60 or > 180/120; P < 60 or > 120; T > 102.5; RR < 12 or > 28; Respiratory distress or decreased LOC | 02 @ 2, 4, 6 L/min via NC or FM; Ceftriaxone (Rocephin) 1 GM IVPB STAT after blood culture; Zithromycin 500 mg IV or PO daily; Levaquin 500 mg IV or PO daily; Tylenol 650 mg PO every 4-6 hrs prn pain/fever; MOM 30 mL PO every 12 hrs prn constipation; Ambien 10 mg PO @ bedtime prn insomnia; Other meds: _____ | Dextrose 5% in 1/2 normal saline with 20 mEq KCL @ ______mL/hr; IV lock, flush per routine | CBC, basal metabolic profile; Blood cultures x2 STAT prior to antibiotics ; Sputum for gram stain, C&S and consider AFB | Chest X-ray: PA & Lat if not done previously | Smoking cessation counseling | Influenza Vaccine (September-March); Administer influenza vaccine 0.5 mL on day of discharge; Patient has been immunized this flu season; Immunization not indicated due to______Pneumococcal vaccine (year round); Administer pneumococcal vaccine 0.5 mL on day of discharge; Patient previously immunized after age 65 years; Patient previously immunized before age 65; but < 5 years ago; Immunization not indicated due to______ | ||||||||||||||||
| Croup | Admission; Observation in pediatric unit | Croup | J05.1 | Acute epiglottitis | Stable; Fair; Serious; Critical | Clear liquids; Diet for age | Bed rest; Up ad lib | Vital signs Per unit routine; Every 4 hrs if on oxygen therapy; I&O every shift | Decadron _____mg IM now (0.6 mg/kg body weight); Decadron elixir 0.5 mg/5mL ______mg PO now (0.6 mg/kg body weight); Prelone elixir 12 mg/mL ______mg PO BID for ______ days (1 mg/kg/dose); Tylenol _____mg PO or PR every 4 hrs prn; temp > 100.4 (10-15 mg/kg/dose); Motrin _____mg PO every 6 hrs prn; temp > 100.4 (10 mg/kg/dose) | No IV required; Bolus with _____mL normal saline over 1-2 hrs (10-20 mL/kg bolus); Maintenance IV with Dextrose 5% in 1/4 normal saline @ _____mL/hr, add 20 mEq KCL after first void | CBC, Lytes | AP/Lateral Neck X-ray: Indicated in atypical cases such as child > age 6, suspected foreign body or unresponsive to therapy | Respiratory: Use croup score; If score > 5, notify MD; If score 2 or greater: continue oximetry, racemic epinephrine (2.25%) nebulizer; 0.25 mL in 3 mL normal saline if < 1 year old or less than 20 kg; 0.50 mL in 3 mL normal saline if > 1 year old; May repeat dose every 4 hrs, notify MD if child needs more frequent doses; O2 @ 2-4 L/min via nasal cannula or face mask to keep O2 sat > 95% | |||||||||||||||||
| CVA | Observation; Admission; Medical floor; Monitored bed; Other | CVA | I67.9 | Cerebrovascular disease, unspecified | Stable; Fair; Serious; Critical | Full Code; DNR | NPO; Clear liquid; AHA step 2; ADA ______ calories; Other | Bed rest; Bed rest with bedside commode; Bathroom privileges with assistance | Vital signs with neuro checks every 4 hrs for 24 hrs then per routinel Notify MD for: BP systolic < 90 or > 180 or > 105 diastolic; P < 60 or > 120; declining mental status or worsening of neurological symptomsl Weight on arrivall I&O every shiftl O2 @ 2, 4, 6 L/min via NC or FMl Check pulse ox on arrival and prn to maintain O2 sat > 92% | ASA 81 mg PO daily; Folate 1 mg PO daily | Dextrose 5% in 1/2 normal saline with 20 mEq KCl/L at 80mL/hr; Hep lock; Other ______ | Admission: CBC, PT/INR, comp met profile, cardiac profile; a.m.: lipid profile, TSH | CT Head without contrast (if not done in ER); ECG (if not done in ER); Portable CXR (if not one in ER); Echocardiogram-to be ready by _____; Other ______ | PT evaluation; OT evaluation; Speech/swallow evaluation |
