Standardized Hospital Admission Orders

$79 / year

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.

Complexity

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

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

John Snow Labs Standard License

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

Name Description Type Constraints
Admission_Order_NameName of admission orderstringrequired : 1
Patient_NameName of the patientstring-
Patient_AgePatient's agestring-
Patient_Date_of_Birthpatient's date of birthstring-
Medical_Record_NumberMedical record numberstring-
StatusStatus of admission. "____" specifies that a value needs to be filled by physicians/nurses in these blanks.stringrequired : 1
Attending_Doctor_NameName of attending physicianstring-
Attending_Doctor_PhonePhone number of attending physicianstring-
Admitting_DiagnosisDiagnosis at the time of admission. "____" specifies that a value needs to be filled by physicians/nurses in these blanks.stringrequired : 1
ICD_10_CM_CodesICD-10-CM codes for Admitting_Diagnosisstringrequired : 1
ICD_10_CM_Codes_DescriptionDescription of ICD-10-CM codes for Admitting_Diagnosisstringrequired : 1
Associated_or_Contributing_DiagnosisAssociated/accompanying diagnosesstring-
Patient_ConditionCondition of patient at the time of admissionstringrequired : 1
Code_StatusValue: Full Code, DNR (Do-Not-Resuscitate order)string-
AllergiesAllergies, if anystring-
DietRecommended diet. "____" specifies that a value needs to be filled by physicians/nurses in these blanks.string-
ActivityAtivity restrcition, if anystring-
Nursing_ResponsibilitiesNursing Orders. "____" specifies that a value needs to be filled by physicians/nurses in these blanks.string-
MedicationsList of Medications prescribed for the treatment. "____" specifies that a value needs to be filled by physicians/nurses in these blanks.string-
IV_AdministrationIV given for the treatment. "____" specifies that a value needs to be filled by physicians/nurses in these blanks.string-
Laboratory_TestsLab tests performed. "____" specifies that a value needs to be filled by physicians/nurses in these blanks.string-
Radiology_ProceduresRadiology procedures performedstring-
Nursing_ConsiderationsMedications or tests to consider, if anystring-
Diagnostic_StudiesDiagnostic studies done on patient's conditionstring-
DecisionDecision made, as part of patient care planstring-
ConsultConsultation recommended to patientstring-
Patient_EducationPatient educationstring-
Follow_UpFollow-up plans, if any. "____" specifies that a value needs to be filled by physicians/nurses in these blanks.string-
ImmunizationsDecision related to immunizationstring-
Other_OrdersMiscellaneous orders, if anystring-
Date_And_TimeDate and time of visit.string-
Admission_Order_NamePatient_NamePatient_AgePatient_Date_of_BirthMedical_Record_NumberStatusAttending_Doctor_NameAttending_Doctor_PhoneAdmitting_DiagnosisICD_10_CM_CodesICD_10_CM_Codes_DescriptionAssociated_or_Contributing_DiagnosisPatient_ConditionCode_StatusAllergiesDietActivityNursing_ResponsibilitiesMedicationsIV_AdministrationLaboratory_TestsRadiology_ProceduresNursing_ConsiderationsDiagnostic_StudiesDecisionConsultPatient_EducationFollow_UpImmunizationsOther_OrdersDate_And_Time
Intractable Headache 23 hr observationIntractable HeadacheG43.911Migraine, unspecified, intractable, with status migrainosusStable; Fair; Serious; CriticalRegular; but no caffeineNotify MD for: T > 100, P < 60 or > 120, BP < 90/60 or > 170/110No 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: _____HeplockHemogram, basal metabolic profile
Hypernatremia Observation; Admission; Monitored bed; ICUHypernatremiaE87.0Hyperosmolality and hypernatremiaStable; Fair; Serious; CriticalBed rest and up in chair as tolerated Notify MD for T > 101, BP > 190/100 or < 90/60, neuro changesHypovolemic: _____ 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; OtherASA overdoseT39.014Poisoning by aspirin, undetermined, initial encounterStable; Fair; Serious; CriticalFull Code; DNRNPO; Clear Liquid; AHA step 2; ADA; OtherBed rest with bathroom privilegesVital 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/dlVitamin K 10 mg IM now; Guaiac all stools; OtherDextrose 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 ERPsych; Social services; MHMR
Lower Gi Bleed Medical; Telemetry; ICULower GI BleedK92.2Gastrointestinal hemorrhageStable; Fair; Serious; CriticalNPO except meds; OtherBed rest with bedside commode; Bathroom privileges with assistanceICU: 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 resultsBolus normal saline _____cc over _____; Dextrose 5% normal saline with 20 mEq KCl/L @ _____mL/hr totalHemogram, comp met profile, PT/PTT/INR on admission; HH every 6 hrs X24 hrs; Type and screen for _____units PRBCHave patient sign informed consent form for blood transfusion.
Upper GI Bleed Observation; Admission; Medical Floor; Telemetry; ICUUpper GI BleedK92.2Gastrointestinal hemorrhageStable; Fair; Serious; CriticalNPO except meds, NPO including medsBed rest with bedside commode; Bathroom privileges with assistanceICU: 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 hrsProtonix 40 mg PO/IV every 12 hrs; Other: ___Bolus normal saline _____cc over ______; Dextrose 5% normal saline with 20mEq KCl/l @ _____mL/hr totalHemogram, 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; AdmissionPediatric vomiting/diarrhea/dehydrationR11.10; R19.7; E86.0Vomiting unspecified; Diarrhea unspecified; DehydrationStable; Fair; Serious; CriticalNPO; Formula/Breast; Age appropriate diet as toleratedCrib; Bassinet; BedVital signs: every 4 hrsTylenol (10 mg/kg) _____ PO/PR every 4 hrs prn T > 101; Phenergan 12.5-25 mg PR 1 6-8 hrs prn n/vReplacement (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 maintenanceBasal 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; AdmissionPartial Small Bowel ObstructionK56.60Unspecified intestinal obstructionStable; Fair; Serious; CriticalNPO Bed rest with bathroom privileges with assistanceVital 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&ODemerol 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 hrsDaily hemogram, basal metabolic profile in a.m.X-ray: acute abdominal series if not done in ER/clinicSurgical 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; ICUHyponatremiaE87.1Hypo-osmolality and hyponatremiaStable; Fair; Serious; CriticalFull Code; DNRNPO; Clear liquid; AHA step 2; ADA ______ calories; OtherBed rest with bathroom privileges with assistanceOrthostatic VS every 4 hrs until stable x4, then every shift; Notify MD for: T > 101, BP < 90/60 or > 190/100, neuro changesHypovolemic: ______ 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/hrCMP, UA, urine Na+, TSH, urine OSM, plasma osmolality and CXR on arrival daily BMPDVT 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; OtherPyelonephritisN10Acute pyelonephritisStable; Fair; Serious; CriticalFull Code; DNRNPO; Clear liquid; AHA step 2; ADA ______ calories; OtherBed rest with beside commode; Bathroom privileges; Up ad libVital 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&OLevaquin 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 indicatedDextrose 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: CBCIf 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; ICUSeizure DisorderG40.89Other seizuresStable; Fair; Serious; CriticalBed rest with seizure precautionsVital 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 < 15Dilantin 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
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