order writing slides
TRANSCRIPT
-
8/12/2019 Order Writing Slides
1/22
Order WritingInternal Medicine Clerkship
-
8/12/2019 Order Writing Slides
2/22
ADC VAAN DISML
Essentials:
ClarityDate, Time, Signature
Appropriate RankRe-evaluate
-
8/12/2019 Order Writing Slides
3/22
Order Writing
ADC VAAN DISML
Admit Order Location Attending Physician
Admit Mr. Jones to 6B, monitored bed, for Dr. Frank
-
8/12/2019 Order Writing Slides
4/22
Order Writing
ADC VAAN DISML
Diagnosis Chief complaint or problem(s)
Diagnosis: Unstable Angina
-
8/12/2019 Order Writing Slides
5/22
Order WritingADC VAAN DISML = Condition
Good
Fair
Poor
Guarded
Critical
No anticipated complications; pt.Stable
Pt. Is ill, may have complications
Very ill pt., chronically orterminally ill, not very stable
Very ill pt., clinical outcome not
predictable
Desperately ill, unstable patient
Condition: Stable
-
8/12/2019 Order Writing Slides
6/22
Order Writing
ADC VAAN DISML = Vital Signs (T, P, R, BP)
Patients 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< 60, SBP>150 or
-
8/12/2019 Order Writing Slides
7/22
Order Writing
ADC VAAN DISML = Activity
Restricted/EncouragedBed rest
Bed rest with bathroom privileges/bedsidecommodeUp in chair/hallWalk with assistance - how often
Up ad lib
Bed rest. Up to bathroom with assistance
-
8/12/2019 Order Writing Slides
8/22
Order Writing
ADC VAAN DISML
Allergies
Include what they are allergic to and whatreaction they get
Allergies: Penicillin - Hives and Wheezing
-
8/12/2019 Order Writing Slides
9/22
Order Writing
ADC VAAN DISML= Nursing Instructions
Intake and Output Daily weights Patient positioning/turning Wound care Foley catheter, nasogastric tubeCall orders - e. g. pain, urine output
1. Intake and Output2. If patient develops chest pain, give 0.4 mg nitroglycerin s.l.,
obtain 12-lead EKG and call me stat on pager 1234
-
8/12/2019 Order Writing Slides
10/22
Order WritingADC VAAN DISML=Diet/Nutrition
Oral Nutrition - restricted or normal diet diabetes, renal or liver disease
NPO for altered mental status, pre-
surgical patients, some abdominalproblems
If NPO, need order for alternativehydration and nutrition
Two gram sodium diet today, then n.p.o. after midnight
-
8/12/2019 Order Writing Slides
11/22
ADC VAAN DISML =Diet/Nutrition
Short term intravenous therapy Electrolyte solutions
Long term intravenous therapy parenteral or enteral nutrition
-
8/12/2019 Order Writing Slides
12/22
Order WritingADC VAAN DISML=Intravenous Fluids
Be specific about composition, rate ofadministration and quantity D5W - 5 % Dextrose in Water
D5NS - 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
-
8/12/2019 Order Writing Slides
13/22
Order WritingADC VAAN DISML=Special Studies andConsults
Imaging studies - X-ray, sonograms, CTs 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-ray2. EKG, stat3. Dr. Frank to see, please - I
have notified him
-
8/12/2019 Order Writing Slides
14/22
Order WritingADC VAAN DISML =
Medications
Dosage
Route of Administration
Be specific with prn orders Review medications daily
Be specific when making changes. Cancelprevious orders
If stat, communicate directly with nurse
-
8/12/2019 Order Writing Slides
15/22
ADC VAAN DISML = Medications
1. ASA 325 mg., p.o. now2. Start i.v. nitroglycerin drip at 10
mcg/min. Increase rate by 5 mcg/minevery 15 minutes until systolic BP is 110,or until chest pain is relieved. Call me ifrate of 30 mcg/min is reached, or if chestpain is not relieved
3. Infuse heparin bolus 5000 units i.v., andfollow by heparin drip at 1000 units/hour
4. Metoprolol 50 mg. p.o. BID
-
8/12/2019 Order Writing Slides
16/22
Type and Crossmatch Orders
Be specific about blood productdesired packed cells, whole blood, platelets,cryoprecipitate
Clearly state how many units desired
Clearly state what you want done
Type and Cross order should precedetransfuse order
Type and Cross 4 units of PRBCs. Transfuse two units now;
Hold two units in blood bank
-
8/12/2019 Order Writing Slides
17/22
Order WritingADC VAAN DISML =
Laboratory Studies
Avoid orders for daily blood work
phlebotomy associated anemia not uncommon
Timing important for fasting levels, somedrug levels
1. CBC, Cardiac Enzymes, Troponin I, BMP, PT, INR, PTT stat
2. Repeat Cardiac enzymes and troponin q 6 hours x33. Re eat EKG 6 hours x3
-
8/12/2019 Order Writing Slides
18/22
THANK YOU,
Jane Jones, MSIII
-
8/12/2019 Order Writing Slides
19/22
Dont forget to date and
time all orders and notes!
-
8/12/2019 Order Writing Slides
20/22
Prescription Writing
Patients full name and DOB
Date
Rx Drug Namegeneric 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
-
8/12/2019 Order Writing Slides
21/22
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 IIdrugs.
-
8/12/2019 Order Writing Slides
22/22
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) whenpoorly written.
Write unit(s)
g
Mistaken for "mg" (milligrams) when written, resulting in an overdose.
Write microgram(s) or mcg