Chapter 1. Clinical Pearls for the Wards

Admission Orders (ADC VANDALISM)

• 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

Preoperative Orders

• 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

Discharge Orders

• 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

On-Service Note

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

Progress Note (SOAP Note)

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

Objective:

• 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

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

Plan (problem based or system based)

Discharge Summary (Usually Dictated)

• 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