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Admission Orders (ADC VANDALISM)

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  • Admit to: Floor, service, MD
  • Diagnoses (prioritized)
  • Condition: Good, fair, poor, guarded, critical
  • Vitals and monitoring: Frequency of monitoring (eg,, q4, q shift, per routine), type of monitoring (eg, continuous oximetry, telemetry, arterial line, CVP, end-tidal CO2)
  • Activity: Ad lib, bed rest with or without bathroom privileges, crib with side rails up, restrictions, ambulate TID, and so on
  • Nursing/respiratory: strict I/O, daily weights, turn patient q shift, dressing care and changes, drain care, NG care, Foley care, suctioning, pulmonary toilet
  • Diet: Regular, clear liquid, special requirements (ie, ADA, low fat, low calorie), restrictions (ie, 2-g sodium renal diet), NPO
  • Allergies: Medication and food
  • Labs
  • IVF: Type, volume, rate (specify mL/hr for all; for infants, also specify mL/kg/d)
  • Studies
  • Medications: Name, dose (also specify mg/kg), frequency, route, duration, reason

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Preoperative Orders

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  • Diagnoses (prioritized)
  • Procedure
  • Preoperative labs (including blood bank orders)
  • Preoperative studies
  • Diet: NPO/IVF after midnight, and so on
  • Consent form signed and on chart
  • H&P reviewed

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Discharge Orders

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  • Discharge: When, to where
  • Diagnoses (prioritized)
  • Diet
  • Condition
  • Activity: Ad lib, bedrest, physical limitations, and so on
  • Special needs: Home health needs, monitoring, and so on
  • Discharge medications
  • Discharge instructions: When and why to return, where to return, and so on
  • Follow-up appointments

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On-Service Note

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  • Admit date
  • Admit diagnoses (prioritized)
  • Hospital course summary
  • Physical examination
  • Problem list (prioritized)
  • Assessment or plan (problem based or system based)

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Progress Note (SOAP Note)

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Subjective: Patient comments or complaints, nursing comments, relevant events

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Objective:

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  • Vitals: Temperature, HR, RR, blood pressure, oxygen saturation, weight (including change from previous)
  • I/O: Totals and components of IVF, PO intake, emesis, residuals, urine, stool, drains
  • Physical examination (focused)
  • Medicines: All current medicines with weight-based dose (scheduled and prn)
  • Laboratory and test data: New or pending

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Assessment: Analysis of above, including differential dx or tentative dx

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Plan (problem based or system based)

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Discharge Summary (Usually Dictated)

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  • Admission and discharge date
  • Admission and discharge diagnoses (prioritized)
  • Service: Service name, attending physician, resident(s)
  • Consulting services
  • Procedures
  • Physical examination and vitals (admission)
  • Hospital course (system based or problem based, pertinent labs and studies)
  • Physical examination and vitals (discharge)
  • Discharge condition: Improved, good
  • Disposition: To outside hospital, home, hospice, and so on
  • Discharge medications: Name, formulation, dosage, length of treatment, refills
  • Discharge activity
  • Discharge diet
  • Discharge instructions: Dressing or cast care, symptoms to warrant further treatment, where to return for further treatment, and so on
  • Follow-up appointments

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Identifying Information: Name, date, weight, DOB

Rx: Drug name, strength, formulation (ie, amoxicillin 250 mg/5 suspension)

SIG: Quantity (mL, tablets, ...

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