Admitting a Patient to the Hospital_Admit Orders

Admitting a Patient to the Hospital

MARC IMHOTEP CRAY, M.D.

Objective  List the specific components of typical admit orders using common mnemonics.  Describe the rules for effective order writing.  Explain each of the specific components of typical admit orders.

Marc Imhotep Cray, M.D.

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On-Call Night Admissions  Third-year medical students are generally expected to admit anywhere from 1 to 3 patients on a call night (Internal Medicine Clerkship )  Typically, resident will receive a call w a 1-line description of patient such as “33-year-old African American female with abdominal pain.”  On basis of this description, you should start formulating a differential diagnosis by following means: o o o o

Review objective data (e.g., paperwork from paramedics or ED) Interview the patient (medical history) Conduct a thorough physical examination.

Present your patient to your Resident with a leading Dx and plan

Marc Imhotep Cray, M.D.

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Introduction to Admit Orders  Admit orders should be entered before your admission H & P is completed  Once you have a working diagnosis and a skeletal management plan begin entering orders  Many hospitals w electronic order entry have automated admission order sets, however it is important to be able to write out admit orders

Marc Imhotep Cray, M.D.

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Intro. to Admit Orders cont’d. When a patient is admitted to hospital, orders written at time of admission direct healthcare team in caring for pt. 

important orders are completed in a timely manner and are unambiguous

Once written, an order is considered to be in effect until another order is written to change or stop original order unless a time limit is provided in original order…(see next slide) Marc Imhotep Cray, M.D.

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Intro. to Admit Orders cont’d.

For example An order to record intake and output (I&Os) would be carried out until an order is written to discontinue (d/c) intake and output An order for Ancef 1 g IV q 24 hr x 3 days will be given only for 3 days thus, not necessary to write an order to stop Ancef

Marc Imhotep Cray, M.D.

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Intro. to Admit Orders cont’d. At some facilities, it is acceptable to use prewritten order sets  Developed for conditions that require hospital admission so often same orders would be written over and over, such as: o chest pain, rule out acute myocardial infarction (AMI) o cerebrovascular accident (CVA) or o preoperative care

 There is an established protocol for development, review, and acceptance of order sets o involves medical staff members from various disciplines, nursing staff, pharmacists… etc.

Marc Imhotep Cray, M.D.

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Admission Orders Mnemonic NB: Crucial that admit orders are organized and thorough.

Each set of orders should contain certain elements. There are several mnemonics that help you remember what admission orders should be written  One mnemonic is AD CAVA DIMPLS which stands for o o o o o o o o o o o o

Admit, Diagnosis, Condition, Activity, Vital signs, Allergies, Diet, Interventions, Medications, Procedures, Labs, and Special instructions

Marc Imhotep Cray, M.D.

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nd A2

commonly used Admit orders Mnemonic ADC VANDALISM o o o o o o o o o o o o

Admit to Diagnosis Condition Vitals Allergies Nursing orders Diet Activity Labs IV fluids Special studies Medications

Marc Imhotep Cray, M.D.

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rd A3

commonly used Admit orders Mnemonic The letters in ADCA VAN DIMLS + D stand for: o o o o o o o o o o o o

A Admit to D Diagnosis C Condition A Allergies V Vital signs A Activity N Nursing orders D Diet I IV orders M Medication orders L Lab and other orders S Special orders + o D Discharge planning Marc Imhotep Cray, M.D.

Here we’ve added one additional letter to traditional mnemonic—D for ‘‘discharge planning,’’ now a critical part of patient’s plan of care, even at time of admission.

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Admission Orders Mnemonic cont’d.

AD CAVA DIMPLS o o o o o o o o o

Admit: admitting physician and type of unit or hospital floor Diagnosis: chief reason for the patient’s admission Condition: usually a one-word description Activity: level of activity allowed depending on age, diagnosis, medications, etc.

Vital signs: frequency with which vital signs should be obtained Allergies: list any medication allergies Diet: what type of diet patient is allowed Interventions: IV therapy, respiratory therapy, etc.

Medications: medications related to reason for admission and any chronic medications patient may be taking o Procedures: wound care, ostomy care, etc. o Labs: any laboratory or diagnostic tests needed o Special instructions: notify if certain parameters are exceeded, or conditional orders (if this occurs, do this)

Marc Imhotep Cray, M.D.

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Rules for Effective Order Writing 1. Write legiblyďƒ may seem obvious, but illegible handwriting still leads to many errors and, even more, calls requesting clarification 2. Date and time every order 3. Be clear and specific, especially when asking others to do something

Marc Imhotep Cray, M.D.

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Rules for Effective Order Writing cont’d.

4. Be respectful of other professionals’ time and expertise 

Don’t request every 4 hours postural vital signs or every 2 hours lab draws unless you have a clear reason to do so, and have discussed it with staff

NB: Writing ‘‘please’’ and ‘‘thank you’’ can go a long way

Marc Imhotep Cray, M.D.

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Rules for Effective Order Writing cont’d.

5. Have a plan in mind when writing your admit orders  This may only be a plan for the next few hours for an unstable patient  Ideally it will also include a general plan for hospitalization and discharge  Having a plan in mind helps you to be complete in writing orders and helps nursing and other staff prioritize tasks

Note: Single orders that dribble in over a period of hours are much less effective Marc Imhotep Cray, M.D.

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Admit Specify admitting physician and hospital unit to which patient should be admitted  Admit to Dr. Cray, orthopedic floor or  Admit to telemetry unit, Dr. Ali’s service

Marc Imhotep Cray, M.D.

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Diagnosis State admitting diagnosis and,  in case of a surgical admission, include name of procedure to be performed When a pt. has more than one admitting diagnosis problem most responsible for admission should be listed as primary diagnosis  Comorbid conditions that should be monitored during hospital stay are documented as additional diagnoses  Primary diagnosis: pneumonia  Secondary diagnosis: type 2 diabetes

Marc Imhotep Cray, M.D.

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Condition  This reflects pt’s condition at time of admission 

If pt. has terminal cancer and is likely to die within a few hours condition should reflect that

 Words commonly used to describe condition are stable, unstable, guarded, critical, morbid, and comatose

Marc Imhotep Cray, M.D.

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Activity Indicate level of activity pt. is permitted to have There are several activity orders commonly used condition of pt. (including mental alertness) and overall health condition of pt. determine which order is most appropriate…see next slide

Marc Imhotep Cray, M.D.

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Activity cont’d.

Common activity orders include following:  Up ad lib ( pt. may be out of bed as he or she wishes)  Activity as tolerated (whatever condition allows pt. to do)  Bedrest with bathroom privileges, abbreviated as BR with BRP (allowed out of bed to go to bathroom; otherwise in bed)  Out of bed (OOB)  Ambulate a certain number of times a day  Ambulate with assistance  Non–weight-bearing Marc Imhotep Cray, M.D.

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Vital signs This order reflects how often standard vital signs (T, P, R, and BP) should be obtained & will vary according to pt’s condition

 Some hospitals have standing orders for VS depending on type of unit or floor to which pt. is admitted Critical or intensive care units almost always have their own standing VS orders Marc Imhotep Cray, M.D.

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Vital signs cont’d.  Some vital signs are monitored continuously as pt’s condition warrants  For example, BP and HR are monitored continuously in a pt. who recently had a MI

 Typical orders for medical admissions are  VS q8h while awake (if pt. is very stable and if it is not necessary to awaken a pt. to obtain vital signs)  VS q4h

Marc Imhotep Cray, M.D.

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Vital signs cont’d.  Weight is generally obtained at time of admission only  If a pt’s condition necessitates monitoring of volume status or renal function, as in case of heart failure, edema or fluid retention write an order to weigh daily

Marc Imhotep Cray, M.D.

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Allergies  Not actually an order but rather a specific notation of allergies pt. may have to any medication, food, or other substance

 It is customary to include specific agent pt. is allergic to and what reaction pt. has to agent 

For example, Allergic to penicillin (rash) and aspirin (dyspnea)

Marc Imhotep Cray, M.D.

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Allergies cont’d. Some providers document details of reaction in PMH section of admission H&P and list drugs only in orders this is an acceptable practice If it is hospital policy to identify pts. w allergies by a special armband or other designation a specific order for this is not necessary

Marc Imhotep Cray, M.D.

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Diet  First step in determining which diet order to write is to determine whether it is safe to allow pt. to eat  If pt. is going to have surgery or a procedure that requires sedation and therefore carries a risk for aspiration, or  If pt. is not mentally alert enough or physically able to eat and swallow,

it is safer for pt. not to receive any nourishment by mouth  order for this is NPO, an abbrev. for Latin phrase nil per os, interpreted as nothing by mouth Marc Imhotep Cray, M.D.

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Diet cont’d. If allowing pt. to eat does not pose a threat to safety, there are many dietary orders that can be written  Some of more common types of diets are shown below

Sullivan D. Guide to clinical documentation, 2nd Ed. Philadelphia: F. A. Davis Company, 2012; Table 7-1, 153.

Marc Imhotep Cray, M.D.

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Interventions  Refers to interventions by nursing or other ancillary staff, such as physical therapy or respiratory therapy  For example single volume nebulizer (SVN) with 0.5 cc albuterol in 2.5 cc normal saline (NS) q4h  Another example is Physical therapist (PT) to instruct on bed to wheelchair transfers  Intravenous (IV) therapy is also considered an intervention o An order for IV therapy should specify type of fluid and rate of administration, such as D5NS (5% dextrose in NS) at 80 cc/hr Marc Imhotep Cray, M.D.

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Medications  A study by Bobb and colleagues (2004) looked at etiology of prescribing errors in hospital setting they found that  Almost two thirds of verified prescribing errors identified in study period were made on day of admission  Many of errors were due to incomplete pt. medication histories  Dosing errors were most common preventable medication error Bobb A et al.. The epidemiology of prescribing errors: The potential impact of computerized prescriber order entry. Archives of Internal Medicine, 164:785-791; 2004.

NB: Clinicians should be cognizant of potential for serious adverse drug events (ADE) if medication orders are not carefully and completely written.

Marc Imhotep Cray, M.D.

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Medications cont’d.  Always specify    

name of medication, dose, route of administration, and Frequency

 It is common to write orders, first   

for any medications that are given for condition necessitating hospitalization, then orders for any medications taken before hospitalization that need to be continued, and then orders for any symptomatic medications

Marc Imhotep Cray, M.D.

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Medications cont’d.  Symptomatic medications are those that may or may not be needed 

During a hospitalization, pts. experience sleeplessness, constipation, pain, and nausea with such frequency that orders are typically written at time of admission so that meds are available to treat these symptoms if they develop

 Not only will these orders reduce discomfort for patient they will also prevent nursing staff from having to call a prescriber at 2:00 a.m. to request a sleep aid  These meds would be ordered on a prn basis and are given only as requested by pt. you always want to include indication for giving the prn medication Marc Imhotep Cray, M.D.

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Medications cont’d.  For example An order written as morphine 2 mg IV prn is open for interpretation  Although nursing staff would recognize morphine is a narcotic analgesic and would know that it is given to relieve pain the order is ambiguous o Instead, it should be written with specific dosing, frequency, and indication instructions, such as morphine 2 mg IV q2h prn pain •

This prevents med. from being admin. for reasons other than pain and establishes a safe time frame in which the med. may be admin.

 A specific dose should always be ordered, rather than a range of dosing such as morphine 2–6 mg IV q2-3h prn pain (incorrect) this helps prevent inappropriate administration of the medication Marc Imhotep Cray, M.D.

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Procedures  Many routine procedures are part of a pt’s daily care may seem intuitive they should be performed  However, writing an order for such procedures as daily catheter care, wound or ostomy care, and dressing changes provides justification for performing these procedures and allows hospital to charge for necessary supplies

 Order should specify how frequently procedures should be carried out

Marc Imhotep Cray, M.D.

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Labs (and other diagnostic studies)  It may be necessary to monitor certain laboratory values or obtain diagnostic studies as part of a patient’s care For example,  When a pt. is on an anticoagulant medication you monitor bleeding time  If a patient develops fever and a cough, you might order a chest x-ray (CXR)

Marc Imhotep Cray, M.D.

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Labs cont’d. You should always have a rationale for ordering lab or other diagnostic studies For example,  If a pt. had surgery but had very little intraoperative bleeding it is unnecessary to order H&H (hematocrit and hemoglobin) qam you would not expect values to change b/c there was little blood loss

Marc Imhotep Cray, M.D.

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Labs cont’d.  When ordering radiographic studies indication for study should be included, not only to aid radiology staff in interpreting study, but also to establish relevance of the study to pt’s overall car 

An example is AP (anteroposterior) & lateral CXR to R/O atelectasis

Marc Imhotep Cray, M.D.

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Special instructions  Rationale for special instruction orders is to ensure that nursing staff informs provider of changes in a patient’s condition that may require some intervention 

For example, results of glucose monitoring above or below a certain level may require withholding, increasing, or decreasing insulin doses o

Marc Imhotep Cray, M.D.

You would write an order to Notify Dr. XX if blood sugar is <100 mg/dL or >350 mg/dL

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Special instructions cont’d.  If a patient was admitted 2 days ago for AMI and now has new onset of atrial fibrillation you want to be alerted to that fact 

You should never assume that nursing staff will automatically notify you of such developments o

o

Marc Imhotep Cray, M.D.

As a general rule, they probably would; however, responsibility of managing changes in pt’s condition rests on the attending medical staff—not nursing staff—and you can only manage what you are aware of Writing special instruction order protects you as a clinician and helps to ensure best treatment for patient

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So, to write complete Admit Orders, rememberâ&#x20AC;Śone of these 3 mnemonics AD CAVA DIMPLS ---Or--- ADC VANDALISM ---Or--- ADCA VAN DIMLS + D o A Admit to o Admit to o Admit, o D Diagnosis o Diagnosis o Diagnosis, o C Condition o Condition o Condition, o A Allergies o Vitals o Activity, o V Vital signs o Allergies o Vital signs, o A Activity o Nursing orders o Allergies, o N Nursing orders o Diet o Diet, o D Diet o Activity o Interventions, o I IV orders o Labs o Medications, o M Medication orders o IV fluids o Procedures, o L Lab and other orders o Special studies o Labs o S Special orders o Special instructions o Medications + o D Discharge planning 38

THE END

See next slide for links to tools and resources for further study.

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Tools & resources for further study: Companion Notes The “How To” of Clinical Wards Write-ups.pdf, includes: • Admission H&P • Admit Orders • Admit Notes • Progress Notes • Procedure Notes Books Le T, Bhushan V, Yeh JS. First Aid for the Wards, 5th Ed. New York: McGraw-Hill, 2013.

McDonough, K. , Larson E. Manual of evidence-based admitting orders and therapeutics. 5th Ed. Philadelphia: Saunders-Elsevier, 2007.

Sullivan D. Guide to clinical documentation, 2nd Ed. Philadelphia: F. A. Davis Company, 2012.

Marc Imhotep Cray, M.D.

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