Guide to Admission Orders

ADMIT ORDERS

Admit To: (Location, Service, MDs, and pagers)
Diagnosis: (chief complaint, or known diagnosis)
Condition: (e.g. Stable, Fair, Guarded, Critical, etc.)
Vitals: (e.g. per routine, q15 min x 4, q4h, q8h, etc.)
Allergies: (drug and food allergies-mention reaction)
Activity: (e.g. bedrest, up with assistance, OOB in chair, BR privileges, etc.)
Nursing: (e.g. daily wt, BID wt, Strict I/O's, dip urines for heme, guaiac all stools, dressing changes BID, routine trach or G-tube cares, etc.)
Diet: (e.g. NPO, Regular for age, ADA diet, Renal diet, Low Na diet, Clears, soft, etc.)
IVF: (Specify solution and rate; remember no KCl until voiding)
Meds: (List all meds with proper dosage, route, and frequency; include patient’s weight)
Exams: (e.g. AP/LAT CXR, Cranial CT w/o Contrast, UGI w/ SBFT, etc.-mention reason when ordering)
Labs: (Note that each institution has different lab nomenclature, so if in doubt spell out each desired lab test)
Other: (e.g. HOB elevated to 30 degrees, Continuous pulse oximetry, CR monitor, seizure precautions, etc.)
Call HO: (Be specific for your concerns, e.g. T>38.0 vs T>40.5, UOP<50 ml/8hrs,  RR<12, O2 SAT< 92%, etc.)