Order Writing

ADC VAAN DISML

Essentials:

ClarityDate, Time, Signature

Appropriate RankRe-evaluate

Order Writing

ADC VAAN DISML

Admit OrderLocation Attending Physician

“Admit Mr. Jones to 6B, monitored bed, for Dr. Frank”

Order Writing

ADC VAAN DISML

Diagnosis◦Chief complaint or problem(s)

“Diagnosis: Acute Coronary Syndrome”

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 or terminally ill, not very stable

Very ill pt., clinical outcome not predictable

Desperately ill, unstable patient

“Condition: Stable”

Order Writing

ADC VAAN DISML = Vital Signs (T, P, R, BP)

Patient’s 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<90”

Order Writing

ADC VAAN DISML = Activity

Restricted/EncouragedBed rest Bed rest with bathroom privileges/bedside commodeUp in chair/hallWalk with assistance - how oftenUp ad lib

“Bed rest. Up to bathroom with assistance”

Order Writing

ADC VAAN DISML

◦Allergies

Include what they are allergic to and what reaction they get

“Allergies: Penicillin - Hives and Wheezing”

Order Writing ADC VAAN DISML= Nursing Instructions

Intake and OutputDaily weightsPatient positioning/turningWound careFoley catheter, nasogastric tube“Call” orders - e. g. pain, urine output

“1. Intake and Output 2. If patient develops chest pain, give 0.4 mg nitroglycerin s.l., obtain 12-lead EKG and call me stat on pager 1234”

Order Writing ADC VAAN DISML=Diet/Nutrition

Oral Nutrition - restricted or normal diet◦diabetes, renal or liver disease

NPO for altered mental status, pre-surgical patients, some abdominal problems

If NPO, need order for alternative hydration and nutrition

“Two gram sodium diet today, then n.p.o. after midnight”

ADC VAAN DISML = Diet/Nutrition

Short term intravenous therapy◦Electrolyte solutions

Long term intravenous therapy◦parenteral or enteral nutrition

Order Writing ADC VAAN DISML=Intravenous Fluids

Be specific about composition, rate of administration and quantity◦D5W - 5 % Dextrose in Water

◦D5½NS - 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”

Order Writing ADC VAAN DISML=Special Studies and Consults

Imaging studies - X-ray, sonograms, CT’sCardiovascular Studies - EKGs, echocardiograms,

dopplersNeurologic studies - EMGs, EEGsProvide explanations when appropriateCommunicate directly with consulting physician

when possible, always in stat situations“1. Portable Chest X-ray 2. EKG, stat 3. Consult Dr. Stuart Frank regarding Acute Coronary Syndrome- I have notified him”

Order Writing ADC VAAN DISML = Medications

DosageRoute of Administration Be specific with prn ordersReview medications dailyBe specific when making changes. Cancel

previous ordersIf stat, communicate directly with nurse

ADC VAAN DISML = Medications

“1. ASA 325 mg., p.o. now x 1 dose 2. Start intravenous nitroglycerin drip at

10 micrograms/min. Increase rate by 5 micrograms/min every 15 minutes until systolic BP is 110, or until chest pain is relieved. Call me if rate of 30 micrograms/min is reached, or if chest pain is not relieved

3. Infuse heparin bolus 5000 units intravenously and follow by heparin drip at 1000 units/hour

4. Metoprolol 50 mg. p.o. BID”

Type and Crossmatch Orders

Be specific about blood product desired◦packed cells, whole blood, platelets,

cryoprecipitateClearly state how many units desiredClearly state what you want doneType and Cross order should precede

transfuse order

“Type and Cross 4 units of PRBCs. Transfuse two units now, each over 4 hours; Hold two units in blood bank”

Order Writing ADC VAAN DISML = Laboratory Studies

Avoid orders for daily blood work◦phlebotomy associated anemia not uncommon

Timing important for fasting levels, some drug levels

“1. CBC, Cardiac Enzymes, Troponin I, BMP, PT, INR, PTT stat 2. Repeat Cardiac enzymes and troponin q 6 hours x3 3. Repeat EKG q 6 hours x3 4. PTT 4 hours after heparin is started”

THANK YOU,

Jane Jones, MSIII

Don’t forget to date and time all orders and notes!

Prescription Writing

Patient’s full name and DOBDateRx

◦Drug Name…generic 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”

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 II drugs.

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) when

poorly written. Write unit(s)

µg Mistaken for "mg" (milligrams) when written, resulting in an overdose. Write microgram(s) or mcg