D- 2108 New/Rev Date 4/29/15 Page 1 of 12 HEIGHT: WEIGHT: ALLERGIES: DIAGNOSIS: General Medicine Admission [2108] ADD ON ORDER SETS ADDITIONAL ORDER SETS [ ] Basal Bolus Insulin Order Set Routine, ONE TIME [ ] Cardiac Heparin Protocol Order Set Routine, ONE TIME [ ] Congestive Heart Failure Add On Order Set Routine, ONE TIME [ ] COPD Chronic Add On Order Set Routine, ONE TIME [ ] COPD Exacerbation Add On Order Set Routine, ONE TIME [ ] Correctional Insulin AC & HS Order Set Routine, ONE TIME [ ] Delirium Care & Prevention Add On Order Set Routine, ONE TIME [ ] Geriatric Add On Order Set Routine, ONE TIME [ ] Heparin Weight Based Protocol Order Set Routine, ONE TIME [ ] Insulin Pump Order Set Routine, ONE TIME [ ] Pneumonia Add On Order Set Routine, ONE TIME Status Orders Status Order (Single Response) ( ) Admit to Inpatient Routine, ONE TIME Admission Service: Admission Level of Care: Admission Diagnosis: Admitting Physician: Comments: Starting ( ) Refer to Observation Routine, ONE TIME Admission Service: Admission Level of Care: Admission Diagnosis: Attending Physician: Comments: Informational: Observation orders require a documented Plan of Care from the ordering practitioner Starting *D2108* * D 2 1 0 8 *
D- 2108 New/Rev Date 4/29/15 Page 2 of 12 Code Status Code Status (Single Response) ( ) Full Code Routine, CONTINUOUS ( ) Do not resuscitate Routine, CONTINUOUS ( ) Partial Code Routine, CONTINUOUS Resuscitation Restrictions: Consults Consults [ ] IP Consult to Social Work Routine, ONE TIME Reason for Consult: For 1 Occurrences [ ] IP Consult to Case Manager Routine, ONE TIME Reason for Consult: For 1 Occurrences [ ] IP Consult to Nutrition Routine, ONE TIME Reason for Consult: For 1 Occurrences [ ] OT eval and treat Routine, UNTIL DISCONTINUED Specific Evaluation: Reason for OT? at 12:00 AM [ ] PT eval and treat Routine, UNTIL DISCONTINUED Reason for PT? at 12:00 AM [ ] SLP eval and treat Routine, ONE TIME Reason for SLP? [ ] IP Consult to Wound Care/Enterostomal Routine, ONE TIME Reason for Consult: For 1 Occurrences Vital Signs Vitals [ ] Vital Signs Routine, EVERY 4 HOURS, [ ] Vital Signs Routine, EVERY SHIFT, While patient awake, [ ] Vital signs with pulse oximetry Routine, EVERY SHIFT,
D- 2108 New/Rev Date 4/29/15 Page 3 of 12 [ ] Notify MD -vital signs (specify) Routine, PRN Systolic BP less than: Systolic BP greater than: Diastolic BP less than: Diastolic BP greater than: Pulse greater than:, For 1 Occurrences [ ] Telemetry Cardiac Monitoring [ ] Telemetry Cardiac Monitoring (ACLS protocol) Routine, ONE TIME, Telemetry Patient Care Guidelines: 1) ACLS protocol 2) Telemetry monitoring 3) Keep SAT 92 or greater 4) O2 for chest pain or SOB,, For 1 Occurrences [ ] Notify MD to determine if ongoing telemetry is needed Routine, ONE TIME, 48 hours after admit to telemetry, +2 at 9:00 AM, For 1 Occurrences [ ] Nurse to place order for ECG for chest pain or rhythm Routine, UNTIL DISCONTINUED, change [ ] Nitroglycerin SL tablet 0.4 mg, Sublingual, EVERY 5 MIN PRN, Chest pain, Every 5 minute prn x 3 doses, For 3 Doses, For 3 Doses If chest pain continues call MD. [ ] Atropine injection 0.5 mg, Intravenous, EVERY 5 MIN PRN, Other, Bradycardia, For 3 Doses, For 3 Doses For symptomatic bradycardia with heart rate less than 50/minute. May repeat twice at 5 min intervals. [ ] Telemetry Observational Monitoring [ ] Telemetry Observational Monitoring Routine, ONE TIME, Remote telemetry monitoring, Starting S, For 1 Occurrences [ ] Notify MD to determine if ongoing telemetry is needed Routine, ONE TIME, 48 hours after admit to telemetry, +2 at 9:00 AM, For 1 Occurrences Nursing Orders Nursing Orders [ ] Notify MD Nursing Communication Routine, UNTIL DISCONTINUED, Notify physician for ***, at 12:00 AM [ ] Neuro checks Routine, EVERY 4 HOURS,, For 3 Occurrences [ ] Oxygen therapy Routine, CONTINUOUS Keep SPO2: >/=92% Device: Nasal Cannula Notify and place order for RT if Oxymizer, Venturi Mask, Non- Rebreather Mask, or High Flow Nasal Cannula is needed and notify physician of increased O2 requirements. May adjust O2 per titration order., [ ] Weigh Patient Routine, EVERY MORNING,, For -1
D- 2108 New/Rev Date 4/29/15 Page 4 of 12 [ ] Intake and output Routine, EVERY 8 HOURS, [ ] Strict intake and output Routine, EVERY 8 HOURS, [ ] Insert Foley Catheter [ ] Insert foley catheter Routine, ONE TIME Indications for foley catheter:, For 1 Occurrences [ ] Discontinue foley catheter Routine, ONE TIME Discontinue foley:, For 1 Occurrences [ ] Urinalysis with reflex microscopic Routine, ONE TIME,, For 1 Occurrences [ ] Intermittent straight cath Routine, EVERY 8 HOURS PRN,, For 200 Occurrences [ ] If unable to void, order bladder scan Routine, ONE TIME,, For 1 Occurrences [ ] Check post void bladder scans Routine, EVERY SHIFT, Call MD if greater than 250 ml.,, For 72 Hours [ ] Isolation Orders [ ] Contact isolation Routine, UNTIL DISCONTINUED, at 12:00 AM [ ] Contact plus isolation Routine, UNTIL DISCONTINUED, at 12:00 AM [ ] Contact and respiratory isolation Routine, UNTIL DISCONTINUED, at 12:00 AM [ ] Contact and airborne isolation Routine, UNTIL DISCONTINUED, at 12:00 AM [ ] Respiratory Isolation Routine, UNTIL DISCONTINUED, at 12:00 AM [ ] Airborne Isolation (Negative Air Pressure) Routine, UNTIL DISCONTINUED, at 12:00 AM [ ] Precaution Orders [ ] Aspiration precautions Routine, CONTINUOUS [ ] Fall precautions Routine, CONTINUOUS [ ] Neutropenic precautions Routine, CONTINUOUS [ ] Seizure precautions Routine, CONTINUOUS [ ] Precaution- specify in comments Routine, CONTINUOUS Respiratory Therapy Respiratory Therapy Orders [ ] Respiratory Care Assess and Treat Respiratory Assess and Treat Policy 2.40.210 Article: "Physician-Ordered Aerosol Therapy Versus Respiratory Therapist-Driven Aerosol Protocol: The Effect on Resource Utilization" (March, 2013) URL: "http://mytch.tchhn.org/forms/_layouts/15/wopiframe2.as px?sourcedoc=/forms/ordersets/os%201554_respirator y%20care%20assess%20and%20treat%20policy%202.4 0.210.pdf&action=default&DefaultItemOpen=1" URL: "http://mytch.tchhn.org/forms/_layouts/15/wopiframe2.as px?sourcedoc=/forms/ordersets/os%201554_respirator y%20care%20assess%20and%20treat%20reference%2 0Article%20(2013).pdf&action=default&DefaultItemOpen=
D- 2108 New/Rev Date 4/29/15 Page 5 of 12 1" [ ] RC Assess and Treat Routine, DAILY, Administer respiratory care using clinical indications and frequency and dosing guidelines based on severity index., [ ] RC Assess and Treat Upon Initiation of Respiratory Care Routine, CONTINUOUS,, For -1 [ ] Albuterol (PROVENTIL) nebulizer solution 2.5 mg, Inhalation, EVERY 2 HOURS PRN, Wheezing, Shortness of Breath, Dyspnea [ ] BAN (BREATH ACTIVATED NEBULIZER) Routine, EVERY 2 HOURS PRN,, For 200 Occurrences [ ] Albuterol-Ipratropium (DUONEB) nebulizer solution 3 ml, Inhalation, EVERY 4 HOURS PRN, Wheezing [ ] BAN (BREATH ACTIVATED NEBULIZER) Routine, EVERY 4 HOURS PRN,, For 200 Occurrences [ ] Alveolar Recruitment Routine, EVERY 4 HOURS PRN, May initiate therapy as indicated for alveolar recruitment, For 200 Occurrences [ ] Mucus Clearance Routine, EVERY 4 HOURS PRN, May initiate therapy as indicated for mucus clearance., For 200 Occurrences Diet/Nutrition SUPPLEMENTS [ ] Supplement- Ensure (for non-diabetic) [ ] ENSURE ORAL SUPPLEMENT Routine, Dietary TID Flavor: [ ] IP Consult to Nutrition Routine, ONE TIME Reason for Consult: Supplement needed [ ] Supplement-Glucerna (for diabetic) [ ] GLUCERNA ORAL SUPPLEMENT Routine, Dietary TID Flavor: [ ] IP Consult to Nutrition Routine, ONE TIME Reason for Consult: Supplement needed, For 1 Occurrences [ ] Supplement-Ensure Clear (for clear diet) [ ] ENSURE CLEAR ORAL SUPPLEMENT Routine, Dietary TID Ensure Clear Flavor: [ ] IP Consult to Nutrition Routine, ONE TIME Reason for Consult: Supplement needed, For 1 Occurrences
D- 2108 New/Rev Date 4/29/15 Page 6 of 12 DIETS [ ] NPO DIET Routine, Diet Q Day NPO restrictions: NPO [ ] NPO After Midnight Routine, After Midnight NPO restrictions: NPO after midnight [ ] REGULAR DIET Routine, Dietary TID Regular Restrictions: Liquid restrictions: [ ] CARDIAC DIET Routine, Dietary TID Cardiac Restrictions: [ ] LIQUID DIET Routine, Dietary TID Liquid restrictions: Color/Temperature Restrictions: [ ] LOW SODIUM DIET Routine, Dietary TID Sodium restrictions: Carbohydrate controlled: [ ] DIABETIC DIET Routine, Dietary TID Carbohydrate controlled: Renal Restrictions:
D- 2108 New/Rev Date 4/29/15 Page 7 of 12 [ ] RENAL DIET Routine, Dietary TID Renal Restrictions: [ ] WEIGHT REDUCTION DIET Routine, Dietary TID Calories: [ ] BARIATRIC DIET Routine, Dietary TID Bariatric Restrictions: [ ] MODIFIED SURGICAL DIET Routine, Dietary TID GI restrictions: Carbohydrate controlled: [ ] DYSPHAGIA 1 PUREED DIET Routine, Dietary TID Dysphagia restrictions: Carbohydrate controlled: [ ] DYSPHAGIA 2 SEMI SOFT DIET Routine, Dietary TID Dysphagia restrictions: Carbohydrate controlled: [ ] DYSPHAGIA 3 MECHANICAL SOFT DIET Routine, Dietary TID Dysphagia restrictions: General type restrictions: Carbohydrate controlled:
D- 2108 New/Rev Date 4/29/15 Page 8 of 12 [ ] OBSTETRICAL DIETS Routine, Dietary TID Department Specific restrictions: Activity Activity [ ] Activity as tolerated Routine, UNTIL DISCONTINUED,, For -1 [ ] Up in chair Routine, 3 TIMES DAILY, Encourage out of bed as much as possible,, For -1 [ ] Out of bed with assistance Routine, ONE TIME,, For -1 [ ] Ambulate patient Routine, 3 TIMES DAILY,, For -1 [ ] Ambulate patient with assistance Routine, 3 TIMES DAILY,, For -1 [ ] Bedrest Routine, UNTIL DISCONTINUED, Transport patient per bed only, turn with assist, heels off bed, ankle pumps,c&db,, For -1 Labs Admission Labs [ ] CBC with differential Routine, ONE TIME,, For 1 Occurrences [ ] Basic metabolic panel (bmp=ep1) Routine, ONE TIME,, For 1 Occurrences [ ] PT (pro time includes inr) Routine, ONE TIME,, For 1 Occurrences [ ] PTT Routine, ONE TIME,, For 1 Occurrences [ ] Liver profile Routine, ONE TIME,, For 1 Occurrences [ ] Magnesium Routine, ONE TIME,, For 1 Occurrences [ ] Phosphorus Routine, ONE TIME,, For 1 Occurrences [ ] Lipase Routine, ONE TIME,, For 1 Occurrences [ ] Ammonia (nh3) Routine, ONE TIME,, For 1 Occurrences [ ] Lactic acid Routine, ONE TIME,, For 1 Occurrences [ ] Troponin Routine, ONE TIME,, For 1 Occurrences [ ] B natriuretic peptide Routine, ONE TIME,, For 1 Occurrences [ ] LDH Routine, ONE TIME,, For 1 Occurrences [ ] Prealbumin Routine, ONE TIME,, For 1 Occurrences [ ] Urinalysis Routine, ONE TIME,, For 1 Occurrences [ ] Urine Culture Orders (panel) [ ] Routine urine culture, foley Routine, ONE TIME,, For 1 Occurrences [ ] Routine urine culture, midstream Routine, ONE TIME,, For 1 Occurrences [ ] Routine urine cult, straight cath Routine, ONE TIME,, For 1 Occurrences [ ] Routine urine cult, condom cath Routine, ONE TIME,, For 1 Occurrences [ ] Routine urine culture Routine, ONE TIME,, For 1 Occurrences [ ] Urine Drug Screen, With Confirmation Routine, ONE TIME,, For 1 Occurrences [ ] Beta hcg qualitative, urine Routine, ONE TIME,, For 1 Occurrences
D- 2108 New/Rev Date 4/29/15 Page 9 of 12 [ ] Two BLOOD CULTURES (peripheral draw from different sites or at different times) [ ] Blood Culture PERIPHERAL DRAW (aerobic & Routine, ONE TIME,, For 1 Occurrences anaerobic) [ ] Blood culture-peripheral DRAW from a different site Routine, ONE TIME,, For 1 Occurrences or at a different time (aerobic & anaerobic) [ ] Blood culture- LINE DRAW (aerobic & anaerobic) Routine, ONE TIME [ ] Routine cult, sputum +gs Routine, ONE TIME,, For 1 Occurrences [ ] ABG Panel ( RT collect) [ ] Blood gas, arterial STAT, ONE TIME,, For 1 Occurrences [ ] RT ABG draw STAT, ONE TIME,, For 1 Occurrences AM Labs [ ] CBC (complete blood count) Routine, TOMORROW AM,, For 1 Occurrences [ ] CBC with differential Routine, TOMORROW AM,, For 1 Occurrences [ ] Pt (pro time includes inr) Routine, TOMORROW AM,, For 1 Occurrences [ ] Basic metabolic panel (bmp=ep1) Routine, TOMORROW AM,, For 1 Occurrences [ ] Magnesium Routine, TOMORROW AM,, For 1 Occurrences [ ] Phosphorus Routine, TOMORROW AM,, For 1 Occurrences [ ] Liver profile Routine, TOMORROW AM,, For 1 Occurrences [ ] Lipase Routine, TOMORROW AM,, For 1 Occurrences [ ] Ammonia (nh3) Routine, TOMORROW AM,, For 1 Occurrences [ ] Tsh (thyroid stimulating hormone) Routine, TOMORROW AM,, For 1 Occurrences [ ] Lipid profile Routine, TOMORROW AM,, For 1 Occurrences [ ] HEMOGLOBIN A1c Routine, TOMORROW AM,, For 1 Occurrences [ ] Vitamin B12 (cyanocobalamin) Routine, TOMORROW AM,, For 1 Occurrences [ ] Folic acid Routine, TOMORROW AM,, For 1 Occurrences [ ] Vitamin D 25 Hydroxy Total Routine, TOMORROW AM,, For 1 Occurrences Diagnostic Tests/Studies Diagnostic Tests/Studies [ ] Portable chest x-ray STAT, 1 TIME IMAGING Reason for exam: Is the patient pregnant? Requested Date: Requested Time: For 1 [ ] ECG STAT, ONE TIME Reason for exam: [ ] 2D ECHO COMPLETE W/ PRN CONTRAST Panel [ ] 2D ECHO COMPLETE PRN CONTRAST/BUBBLE/3D Routine, 1 TIME IMAGING, For 1
D- 2108 New/Rev Date 4/29/15 Page 10 of 12 [ ] perflutren lipid microspheres 0.1-1 ml, Intravenous, ONCE PRN, LV opacification, For 1 Doses IV Therapy IV Therapy Nursing Orders [ ] Insert peripheral IV Routine, ONE TIME,, For 1 Occurrences [ ] OK to access Implanted Port (PAC) Routine, ONE TIME,, For 1 Occurrences IV fluids [ ] sodium chloride infusion 0.9% Intravenous, CONTINUOUS [ ] sodium chloride infusion 0.45% Intravenous, CONTINUOUS [ ] dextrose 5 % and 0.45% NaCl infusion Intravenous, CONTINUOUS VTE Prophylaxis VTE Prophylaxis Pharmacologic (Single Response) Medical VTE Risk Factor Assessment - Padua Surgical VTE Risk Factor Assessment - Caprini Priority Resources for VTE Prophylaxis URL: "http://mytch.tchhn.org/forms/ordersets/padua%20ram.p df?web=1" URL: "http://mytch.tchhn.org/forms/ordersets/caprini%20ram. pdf?web=1" URL: "http://mytch.tchhn.org/forms/ordersets/priority%20resou rces%20for%20vte%20prophylaxis.pdf?" ( ) Heparin (porcine) injection 5,000 Units, Subcutaneous, EVERY 12 HOURS ( ) Heparin (porcine) injection 5,000 Units, Subcutaneous, EVERY 8 HOURS ( ) Enoxaparin syringe (Lovenox) 40 mg Daily * 40 mg, Subcutaneous, DAILY, STANDARD dose*: Requires CrCl GREATER than 30 ml/min : ( ) Enoxaparin syringe (Lovenox) 30 mg bid *HIGH dose*: 30 mg, Subcutaneous, 2 TIMES DAILY, Requires CrCl GREATER than 30 ml/min : ( ) Enoxaparin syringe (Lovenox) 30 mg Daily: For Non- 30 mg, Subcutaneous, DAILY Dialysis patients with CrCl 15-30 ml/min ( ) Fondaparinux (ARIXTRA) 2.5 mg Daily: Requires CrCl GREATER than 30 ml/min, with history of heparin induced thrombocytopenia: 2.5 mg, Subcutaneous, DAILY For CrCl GREATER than 30 ml/min, With ( or suspected) Heparin Induced Thrombocytopenia ( ) NO Pharmacologic VTE prophylaxis needed. Must provide reason. Routine, ONE TIME Reason for no DVT Pharmacologic Prophylaxis:, For 1 Occurrences
D- 2108 New/Rev Date 4/29/15 Page 11 of 12 VTE Prophylaxis Mechanical (Single Response) ( ) Place Sequential Compression Devices (SCD) for a minimum of 18 hours/day ( ) NO mechanical VTE prophylaxis needed. Must provide reason Routine, UNTIL DISCONTINUED Laterality: Height: Routine, UNTIL DISCONTINUED Reason for no mechanical VTE Prophylaxis: Medications Pain / Fever [ ] acetaminophen (TYLENOL) tablet 650 mg, Oral, EVERY 6 HOURS PRN, Fever, Mild Pain, Headaches [ ] acetaminophen (TYLENOL) suppository 650 mg, Rectal, EVERY 6 HOURS PRN, Fever, Mild Pain, Headaches [ ] ibuprofen (MOTRIN) tablet 400 mg, Oral, EVERY 6 HOURS PRN, Mild Pain [ ] Hydrocodone-Acetaminophen (NORCO) 5-325 mg per tablet 1-2 Tab, Oral, EVERY 4 HOURS PRN, Moderate Pain(Uncomfortable) [ ] oxycodone-acetaminophen (PERCOCET) 5-325 mg per tablet 1-2 Tab, Oral, EVERY 4 HOURS PRN, Moderate Pain(Uncomfortable) [ ] morphine injection 2-4 mg, Intravenous, EVERY 4 HOURS PRN, Severe Pain [ ] HYDROmorphone (Dilaudid) injection 0.5-1 mg, Intravenous, EVERY 4 HOURS PRN, Severe Pain Constipation / Heartburn / Indigestion [ ] calcium carbonate (TUMS) 200 mg calcium (500 mg) 2 Tab, Oral, 3 TIMES DAILY PRN, Heartburn, Indigestion chewable tablet [ ] bisacodyl (DULCOLAX) EC tablet 5 mg, Oral, DAILY PRN, Constipation [ ] docusate sodium (COLACE) capsule 100 mg, Oral, 2 TIMES DAILY [ ] senna-docusate (SENOKOT-S) 8.6-50 mg per tablet 2 Tab, Oral, 2 TIMES DAILY PRN, Other, constipation [ ] polyethylene glycol (GLYCOLAX) packet 17 g, Oral, DAILY PRN, Constipation Nausea / Vomiting [ ] ondansetron (ZOFRAN) IVP 4 mg, Intravenous, EVERY 6 HOURS PRN, Nausea, Vomiting [ ] promethazine (PHENERGAN) IVP 12.5 mg, Intravenous, EVERY 4 HOURS PRN, Nausea, Vomiting
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