1. Order Writing Jarrod Wall

2. ADC VAAN DISML Essentials:  Clarity  Date, Time, Signature  Legible

3. Order Writing ADC VAAN DISML Admit Order Location Attending Physician “Admit Mr. Jones to 6C, monitored bed, for Dr. Frank”

4. Order Writing ADC VAAN DISML Diagnosis ◦Chief complaint or problem(s) “Diagnosis: Acute Coronary Syndrome”

5. Order Writing ADC VAAN DISML = Condition Good Fair Poor Guarded Critical No anticipated complications; pt. Stable Pt. Is ill, may have complications Very ill pt., chronically or terminally ill, not very stable Very ill pt., clinical outcome not predictable Desperately ill, unstable patient “Condition: Stable”

7. Order Writing ADC VAAN DISML = Vital Signs (T, P, R, BP) Patient’s condition dictates frequency Special variables need orders ◦orthostatics, neuro status, pulse oximetry Review daily “Call” orders “Vital signs q 4 hours. Call if P>100 or 150 or<90”

8. Order Writing ADC VAAN DISML = Activity Restricted/Encouraged Bed rest Bed rest with bathroom privileges/bedside commode Up in chair/hall Walk with assistance - how often Up ad lib “Bed rest. Up to bathroom with assistance”

9. Order Writing ADC VAAN DISML ◦Allergies  Include what they are allergic to and what reaction they get “Allergies: Penicillin - Hives and Wheezing”

10. Order Writing ADC VAAN DISML= Nursing Instructions Intake and Output Daily weights Patient positioning/turning Wound care Foley catheter, nasogastric tube “Call” orders - e. g. pain, urine output “1. Intake and Output 2. If patient develops chest pain, give 0.4 mg nitroglycerin s.l., obtain 12-lead EKG and call me stat on pager 1234”

11. Order Writing ADC VAAN DISML=Diet/Nutrition Oral Nutrition - restricted or normal diet ◦diabetes, renal or liver disease NPO for altered mental status, pre- surgical patients, some abdominal problems If NPO, need order for alternative hydration and nutrition “Two gram sodium diet today, then n.p.o. after midnight”

12. ADC VAAN DISML = Diet/Nutrition Short term intravenous therapy ◦Electrolyte solutions Long term intravenous therapy ◦parenteral or enteral nutrition

13. Order Writing ADC VAAN DISML=Intravenous Fluids Be specific about composition, rate of administration and quantity ◦D 5 W - 5 % Dextrose in Water ◦D 5 ½NS - 5% Dextrose in half normal saline ◦NS - Normal Saline ◦LR - Lactated Ringers solution Example: “Infuse one liter of NS at 500cc/hour, then saline lock” Request pumps when indicated “Place saline lock”

14. Order Writing ADC VAAN DISML=Special Studies and Consults Imaging studies - X-ray, sonograms, CT’s Cardiovascular Studies - EKGs, echocardiograms, dopplers Neurologic studies - EMGs, EEGs Provide explanations when appropriate Communicate directly with consulting physician when possible, always in stat situations “1.Portable Chest X-ray 2.EKG, stat 3.Consult Dr. Stuart Frank regarding Acute Coronary Syndrome- I have notified him”

15. Order Writing ADC VAAN DISML = Medications Dosage Route of Administration Be specific with prn orders Review medications daily Be specific when making changes. Cancel previous orders If stat, communicate directly with nurse

16. ADC VAAN DISML = Medications “1.ASA 325 mg., p.o. now x 1 dose 2.Start intravenous nitroglycerin drip at 10 micrograms/min. Increase rate by 5 micrograms/min every 15 minutes until systolic BP is 110, or until chest pain is relieved. Call me if rate of 30 micrograms/min is reached, or if chest pain is not relieved 3.Infuse heparin bolus 5000 units intravenously and follow by heparin drip at 1000 units/hour 4.Metoprolol 50 mg. p.o. BID”

17. Type and Crossmatch Orders Be specific about blood product desired ◦packed cells, whole blood, platelets, cryoprecipitate Clearly state how many units desired Clearly state what you want done Type and Cross order should precede transfuse order “Type and Cross 4 units of PRBCs. Transfuse two units now, each over 4 hours; Hold two units in blood bank”

18. Order Writing ADC VAAN DISML = Laboratory Studies Avoid orders for daily blood work ◦phlebotomy associated anemia not uncommon Timing important for fasting levels, some drug levels “1. CBC, Cardiac Enzymes, Troponin I, BMP, PT, INR, PTT stat 2. Repeat Cardiac enzymes and troponin q 6 hours x3 3. Repeat EKG q 6 hours x3 4. PTT 4 hours after heparin is started”

19. THANK YOU, Jane Jones, MSIII

20. Case 26yo man 24hr abdominal pain RLQ Fever, nausea PMHx – neg Meds - neg

22. Don’t forget to date and time all orders and notes!

23. Prescription Writing Patient’s full name and DOB Date Rx ◦Drug Name…generic or trade name acceptable ◦Dosage ◦Quantity to be dispensed ◦Directions to patient  how many, how often, what route  how long? With meals?  Avoid “as directed”

24. Prescription Writing Number of refills ◦consider whether acute or chronic illness, abuse potential of drug, possibility of overdose May substitute? ◦Generics are cheaper Signature. DEA number for schedule II drugs.

25. Avoid the Following Abbreviations IU Mistaken as "IV" (intravenous) or 10 (ten). Write international unit(s) MgSO4 Misinterpreted as morphine sulfate, resulting in the wrong medication being administered. Write magnesium sulfate MS / MSO4 / MSO4 Misinterpreted as magnesium sulfate, resulting in the wrong medication being administered. Write morphine Q.D. / QD / q.d. / qd Mistaken for Q.O.D./ qod, resulting in an inappropriate dosing schedule. Write daily Q.O.D. / QOD / q.o.d. / qod Mistaken for Q.D./qd, resulting in an inappropriate dosing schedule. Write every other day T I W Misinterpreted as "three times a day" or "twice a week." Specify days of the week U / u Mistaken as a zero or a four (4), resulting in overdose. Also mistaken for "cc" (cubic centimeters) when poorly written. Write unit(s) µg Mistaken for "mg" (milligrams) when written, resulting in an overdose. Write microgram(s) or mcg