Order Writing Slides

8/12/2019 Order Writing Slides

1/22

Order WritingInternal Medicine Clerkship


2/22

ADC VAAN DISML

Essentials:

ClarityDate, Time, Signature

Appropriate RankRe-evaluate


3/22

Order Writing

ADC VAAN DISML

Admit Order Location Attending Physician

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


4/22

Order Writing

ADC VAAN DISML

Diagnosis Chief complaint or problem(s)

Diagnosis: Unstable Angina


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


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


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


8/22

Order Writing

ADC VAAN DISML

Allergies

Include what they are allergic to and whatreaction they get

Allergies: Penicillin - Hives and Wheezing


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


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


11/22

ADC VAAN DISML =Diet/Nutrition

Short term intravenous therapy Electrolyte solutions

Long term intravenous therapy parenteral or enteral nutrition


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


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


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


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


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


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


18/22

THANK YOU,

Jane Jones, MSIII


19/22

Dont forget to date and

time all orders and notes!


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


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.


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

Documents

Order Writing Slides