1. Admission orders & prescriptions
N. Thomas- Gosain MD MHS
M4 Capstone

2. objectives
Standardized approach to writing admission orders (mnemonic based)
Review components needed for prescriptions
Complete admission orders and prescription writing based on a clinical scenario

3. Why do I need to write orders?
Although many admission orders are available as order sets, need to be able to write orders
When EMRs are down and unable to enter orders electronically
Order sets can be either too comprehensive or too narrow for your individual patient
Inclusion of unnecessary tests or imaging  $$$
Order sets may contain outdated best practices
Why do I need to write orders?

4. Before we begin LEGIBLE Organized Concise and specific
Each page should include:
Pt’s name and identifier (MR#, SSN, DOB) should be on each page
Physician signature (and printed name) along with pager on each page as well
Date and time
All STAT orders should be communicated directly to receiver
Any orders you place will continue until you discontinue them
IVF started on CHF patient who was dehydrated but now with edema

5. errors Place single line through (initial, date and time)
Rewrite order on a separate line
Lisinopril 5mg po daily
Lisinopril 2.5mg po daily
NTG
9/1/19 
15:35

6. ADC VANDALISM Admit to Diagnosis Condition Vitals Allergies Nursing
Diet
Activity
Labs IV
Studies
Medications
ADC VANDALISM

7. ADC VANDALISM
Admit to Level of care & location (observation, step-down, ICU, L&D, SNF, general peds) Telemetry Service (Medicine Team A, Acute Care Surgery, Gyn-Oncology, etc) Isolation (contact, droplet, airborne) Attending Physician, resident physician, intern (with pager numbers) Admit to observation with telemetry, Medicine Team B Attending: Dr. Smith pager zzz-zzzz Resident: Dr. Jones pager yyy-yyyy Intern: Dr. Brown pager xxx-xxxx
Consider nursing care when deciding where to admit a patient.  A hemodynamically stable stroke patient may need q2hr neuro checks that would be impossible for a regular floor nurse to do

8. ADC VANDALISM
Diagnosis: include primary diagnosis along with any other relevant diagnoses that will be monitored during this hospital stay Mrs. Jones presents to the ED with SOB, tachypnea. Her vitals, PE and labs are significant for 99.0°F /95 89% SpO2 on RA Glucose on finger stick is 395 Diagnoses: 1) COPD exacerbation (primary) 2) DM (secondary) 3) HTN (secondary) No need to include pt's glaucoma, breast cancer or eczema (which are all stable) on this list

9. ADC VANDALISM
Condition Good: VS stable, pt comfortable, indicators are excellent Fair: VS stable, pt may be uncomfortable, indicators are favorable Serious: VS may be unstable or not WNL, indicators are questionable Critical: VS unstable, pt may be unconscious, indicators are unfavorable Poor: patient is very ill, chronically or terminally ill, VS may be unstable Guarded: patient is very ill, clinical outcome to be determined

10. ADC VANDALISM
Vitals Encompasses temperature, HR, RR, BP. Need to specify pulse-ox Weight (on admission vs daily) VS routine depends in part on location (q2hr in ICU vs q8hr on medical floor) Also include parameters for nursing to call for abnormal vital signs: “Call for HR > 100 or < 60, BP >140/90 or < 90/50, RR > 22 or < 12, Temp >100.0 or < 96.0” VS q4hrs with pulse-oximetry

11. ADC VANDALISM
Activity Consider overall health as well as mental status Up ad lib Activity as tolerated Bedrest with BRP (bathroom privileges) OOB (out of bed) Up to chair Ambulate with assistance Non weight-bearing

12. ADC VANDALISM Nursing Wound care
Apply duoderm to sacral wound, change q3 days
Strict Ins and outs
Tubes
Insert foley catheter
Place NGT to low intermittent suction
Turn q2hrs
Can also include SCD’s, fall precautions

13. ADC VANDALISM
Diet Consider consistency (full, soft, pureed, clear liquids) Consider diet restrictions based on underlying diseases (DM, renal, cardiac) NPO (nothing per os): make sure to specify if patient is strictly NPO or still able to take meds (NPO except meds) Full diet, NPO after midnight except meds

14. ADC VANDALISM Allergies Specify medication and type of reaction:
PCN (rash)
Can also include pertinent food and enviromental:
Latex (rash)
NKDA

15. ADC VANDALISM
Labs
Specify timing (“in am” or “with next lab draw” vs at 1300)
Be judicious in what you order
One time labs vs regularly scheduled
CBC, CMP in am
CBC, CMP qam for next 3 days
0300
*most hospital labs will call with abnormal results, but not always. Make sure to f/u or signout any lab results that may be critical*

16. ADC VANDALISM
IVF Place peripheral IV Specify type of fluid, rate of infusion as well as amount (if not continuous) Place IV, KVO (keep vein open) when you want IV access but don't necessarily need to start IVF

17. Types of IVF and rate calculations
Normal saline: 0.9NS (isotonic)
Most common
Used for resuscitation, dehydration
½ normal saline: 0.45 NS (hypotonic)
Used in hypernatremia, DKA
D5W: 5% dextrose in water
Diabetics who are NPO
Lactated Ringers: LR (isotonic)
Hypovolemia 2/2 fluid shifts (burn, surgical patients)
4-2-1 rule for calculating maintenance IVF:
First 10kg: 4ml/kg/hr
Next 10kg: 2ml/kg/hr
>20kg: 1ml/kg/hr

18. ADC VANDALISM
Studies Type of study (as specific as possible) and indication Urgency: STAT, in am. If routine, no need to specify (also default) CXR AP (anteroposterior) & lateral (vs portable CXR), indication: SOB, cough CT A/P with and without contrast (if not specified, will likely be done w/o contrast), indication: abdominal pain, h/o diverticulitis EKG STAT for chest pain Can also list consults as well: Consult Nephrology (indication ESRD), routine- already called

19. ADC VANDALISM Medications
Name, dosage, route of administration and frequency
Medication reconciliation
New meds for this hospitalization
Older meds from home (may need to be revised)
ie stopping any stool softeners when pt admitted with diarrhea or stopping anti-hypertensive meds when patient admitted with hypotension
As needed (PRN) meds for symptoms
Typically for nausea, pain, insomnia
Refrain from giving too many ranges
Morphine 5-10mg PO q2-4hrs prn for pain suboptimal
Morphine 5mg PO q1-2 hrs prn for pain better

20. Route of administration
PO (by mouth)
PR (per rectum)
IM (intramuscular)
IV (intravenous)
INH (inhaled)
SL (sublingual)

21. frequency daily (no abbreviation)
every other day (no abbreviation)
BID/b.i.d. (twice a day)
TID/t.id. (three times a day)
QID/q.i.d. (four times a day)
QHS (every bedtime)
Q4h (every 4 hours)
Q4-6h (every 4 to 6 hours)
PRN (as needed)
qd and qod are on the JCAHO "do not use" list
Always specify reason for PRN orders. 
Common reasons include pain, nausea, insomnia, fevers:
ondansetron 4mg PO q8h prn nausea

22. Verbal orders
Rules on when need to be signed vary from hospital to hospital (w/i 24 hours vs w/i 48 hours)
Used in emergencies or when physician is not around
Cannot use verbal orders for following situations:
Post-operative
Code status (DNR)
Withdrawal of life support
PCA
Initial order for IV narcotics
Chemotherapy
TPN

23. Writing prescriptions

24. Prescriptions: essential information
Name of prescriber and contact information (address, phone and fax #s) Patient name and identifying information (usually DOB) and address Date of prescription Rx (Latin “recipere”: to take): drug name, dosage, form (liquid, capsule, tablet) Sig (Latin “signetur”: let it be labeled): directions for use (frequency and route) Disp (dispense): total number to be dispensed (usually listed as number +/- spelled out) Refills: usually no more than a one year supply for chronic meds Generic Signature DEA#

25. physician name & office address
Ideally should include phone # for pharmacy to reach you at
medication name, dosage and number to dispense
Consider writing out # to avoid tampering: 
#30 could be turned into #300, but #30 (thirty) could not 
date
patient name & address
Needs another patient identifier (DOB, SSN)
route & time/ frequency of administration
# of refills
physician signature
most scripts will also let you specify generic substitutions
if you write down a brand name drug and do not specifiy "no generics", pt will be given brand specified

26. Controlled substances
Significant variability among states regarding prescribing controlled substances (amount).  
However DEA mandates that: 
Schedule II: written, signed prescription.  No refills
Schedule III- V: script can be faxed, written or communicated orally to pharmacist.  Up to 5 refills over a 6 month time period allowed 
Gabapentin (Neurontin) is a Schedule V controlled substance in Tennessee as of July 2018