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Admitting a Patient to the Hospital

MARC IMHOTEP CRAY, M.D.


Objective
 List the specific components of typical
admit orders using common mnemonics.

 Describe the rules for effective order


writing.

 Explain each of the specific components of


typical admit orders.

Marc Imhotep Cray, M.D. 2


On-Call Night Admissions
 Third-year medical students are generally expected to admit
anywhere from 1 to 3 patients on a call night (Internal
Medicine Clerkship )

 Typically, resident will receive a call w a 1-line description of


patient such as “33-year-old African American female with
abdominal pain.”
 On basis of this description, you should start formulating a
differential diagnosis by following means:
o Review objective data (e.g., paperwork from paramedics or ED)
o Interview the patient (medical history)
o Conduct a thorough physical examination.
o Present your patient to your Resident with a leading Dx and plan
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Introduction to Admit Orders
 Admit orders should be entered before your
admission H & P is completed
 Once you have a working diagnosis and a skeletal
management plan begin entering orders

 Many hospitals w electronic order entry have


automated admission order sets, however it is
important to be able to write out admit orders

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Intro. to Admit Orders cont’d.
When a patient is admitted to hospital, orders
written at time of admission direct healthcare
team in caring for pt.
 important orders are completed in a timely
manner and are unambiguous

Once written, an order is considered to be in


effect until another order is written to change or
stop original order unless a time limit is
provided in original order…(see next slide)

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Intro. to Admit Orders cont’d.
For example
An order to record intake and output (I&Os)
would be carried out until an order is written to
discontinue (d/c) intake and output

An order for Ancef 1 g IV q 24 hr x 3 days will be


given only for 3 days thus, not necessary to
write an order to stop Ancef

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Intro. to Admit Orders cont’d.
At some facilities, it is acceptable to use
prewritten order sets
 Developed for conditions that require hospital
admission so often same orders would be written
over and over, such as:
o chest pain, rule out acute myocardial infarction (AMI)
o cerebrovascular accident (CVA) or
o preoperative care
 There is an established protocol for development,
review, and acceptance of order sets
o involves medical staff members from various disciplines,
nursing staff, pharmacists… etc.
See: McDonough K, Larson. E. Manual of Evidence-based Admitting Orders and Therapeutics, 5th Ed., Saunders-Elsevier, 2007.

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Admission Orders Mnemonic
NB: Crucial that admit orders are organized and thorough.
Each set of orders should contain certain elements.
There are several mnemonics that help you remember what
admission orders should be written
 One mnemonic is AD CAVA DIMPLS which stands for
o Admit,
o Diagnosis,
o Condition,
o Activity,
o Vital signs,
o Allergies,
o Diet,
o Interventions,
o Medications,
o Procedures,
o Labs, and
o Special instructions

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A2nd commonly used Admit
orders Mnemonic
ADC VANDALISM
o Admit to
o Diagnosis
o Condition
o Vitals
o Allergies
o Nursing orders
o Diet
o Activity
o Labs
o IV fluids
o Special studies
o Medications

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A3rdcommonly used Admit orders
Mnemonic
The letters in ADCA VAN DIMLS + D stand for:
o A Admit to
o D Diagnosis
o C Condition
o A Allergies
o V Vital signs
o A Activity
o N Nursing orders
o D Diet
o I IV orders
o M Medication orders
Here we’ve added one additional letter to
o L Lab and other orders traditional mnemonic—D for ‘‘discharge
o S Special orders planning,’’ now a critical part of patient’s plan of
+ care, even at time of admission.
o D Discharge planning
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Admission Orders Mnemonic cont’d.
AD CAVA DIMPLS
o Admit: admitting physician and type of unit or hospital floor
o Diagnosis: chief reason for the patient’s admission
o Condition: usually a one-word description
o Activity: level of activity allowed depending on age, diagnosis, medications, etc.
o Vital signs: frequency with which vital signs should be obtained
o Allergies: list any medication allergies
o Diet: what type of diet patient is allowed
o Interventions: IV therapy, respiratory therapy, etc.
o Medications: medications related to reason for admission and any chronic
medications patient may be taking
o Procedures: wound care, ostomy care, etc.
o Labs: any laboratory or diagnostic tests needed
o Special instructions: notify if certain parameters are exceeded, or conditional
orders (if this occurs, do this)

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Rules for Effective Order Writing
1. Write legibly may seem obvious, but illegible
handwriting still leads to many errors and, even
more, calls requesting clarification

2. Date and time every order

3. Be clear and specific, especially when asking others


to do something

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Rules for Effective Order Writing
cont’d.
4. Be respectful of other professionals’ time and
expertise
 Don’t request every 4 hours postural vital signs or every
2 hours lab draws unless you have a clear reason to
do so, and have discussed it with staff

NB: Writing ‘‘please’’ and ‘‘thank you’’ can go a


long way

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Rules for Effective Order Writing
cont’d.
5. Have a plan in mind when writing your admit
orders
 This may only be a plan for the next few hours for an
unstable patient
 Ideally it will also include a general plan for
hospitalization and discharge
 Having a plan in mind helps you to be complete in
writing orders and helps nursing and other staff
prioritize tasks
Note: Single orders that dribble in over a period
of hours are much less effective

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Admit
Specify admitting physician and hospital unit to
which patient should be admitted
 Admit to Dr. Cray, orthopedic floor or
 Admit to telemetry unit, Dr. Ali’s service

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Diagnosis
State admitting diagnosis and,  in case of a surgical
admission, include name of procedure to be performed

When a pt. has more than one admitting diagnosis


problem most responsible for admission should be listed
as primary diagnosis

 Comorbid conditions that should be monitored during


hospital stay are documented as additional diagnoses
 Primary diagnosis: pneumonia
 Secondary diagnosis: type 2 diabetes

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Condition
 This reflects pt’s condition at time of admission
 If pt. has terminal cancer and is likely to die within a
few hours condition should reflect that

 Words commonly used to describe condition are


stable, unstable, guarded, critical, morbid, and
comatose

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Activity
Indicate level of activity pt. is permitted to have

There are several activity orders commonly


used condition of pt. (including mental
alertness) and overall health condition of pt.
determine which order is most appropriate…see
next slide

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Activity cont’d.
Common activity orders include following:
 Up ad lib ( pt. may be out of bed as he or she wishes)
 Activity as tolerated (whatever condition allows pt.
to do)
 Bedrest with bathroom privileges, abbreviated as
BR with BRP (allowed out of bed to go to bathroom;
otherwise in bed)
 Out of bed (OOB)
 Ambulate a certain number of times a day
 Ambulate with assistance
 Non–weight-bearing

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Vital signs
This order reflects how often standard vital signs
(T, P, R, and BP) should be obtained & will vary
according to pt’s condition

 Some hospitals have standing orders for VS


depending on type of unit or floor to which pt. is
admitted

Critical or intensive care units almost always


have their own standing VS orders

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Vital signs cont’d.
 Some vital signs are monitored continuously as
pt’s condition warrants
 For example, BP and HR are monitored continuously
in a pt. who recently had a MI

 Typical orders for medical admissions are


 VS q8h while awake (if pt. is very stable and if it is not
necessary to awaken a pt. to obtain vital signs)
 VS q4h

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Vital signs cont’d.
 Weight is generally obtained at time of
admission only

 If a pt’s condition necessitates monitoring of


volume status or renal function, as in case
of heart failure, edema or fluid retention
write an order to weigh daily

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Allergies
 Not actually an order but rather a specific
notation of allergies pt. may have to any
medication, food, or other substance

 It is customary to include specific agent pt. is


allergic to and what reaction pt. has to agent
 For example, Allergic to penicillin (rash) and aspirin
(dyspnea)

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Allergies cont’d.
Some providers document details of reaction in
PMH section of admission H&P and list drugs
only in orders this is an acceptable practice

If it is hospital policy to identify pts. w allergies


by a special armband or other designation a
specific order for this is not necessary

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Diet
 First step in determining which diet order to write
is to determine whether it is safe to allow pt. to eat
 If pt. is going to have surgery or a procedure that
requires sedation and therefore carries a risk for
aspiration, or
 If pt. is not mentally alert enough or physically able to eat
and swallow,
it is safer for pt. not to receive any nourishment by
mouth
 order for this is NPO, an abbrev. for Latin phrase nil
per os, interpreted as nothing by mouth

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Diet cont’d.
If allowing pt. to eat does not pose a threat to safety, there
are many dietary orders that can be written
 Some of more common types of diets are shown below

Sullivan D. Guide to clinical documentation, 2nd Ed. Philadelphia: F. A. Davis Company, 2012; Table 7-1, 153.

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Interventions
 Refers to interventions by nursing or other ancillary
staff, such as physical therapy or respiratory therapy
 For example single volume nebulizer (SVN) with 0.5 cc
albuterol in 2.5 cc normal saline (NS) q4h

 Another example is Physical therapist (PT) to instruct on


bed to wheelchair transfers

 Intravenous (IV) therapy is also considered an


intervention
o An order for IV therapy should specify type of fluid and rate of
administration, such as D5NS (5% dextrose in NS) at 80 cc/hr
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Medications
 A study by Bobb and colleagues (2004) looked at etiology
of prescribing errors in hospital setting they found that
 Almost two thirds of verified prescribing errors identified in study
period were made on day of admission
 Many of errors were due to incomplete pt. medication histories
 Dosing errors were most common preventable medication error
Bobb A et al.. The epidemiology of prescribing errors: The potential impact of
computerized prescriber order entry. Archives of Internal Medicine, 164:785-791; 2004.

NB: Clinicians should be cognizant of potential for serious


adverse drug events (ADE) if medication orders are not
carefully and completely written.

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Medications cont’d.
 Always specify
 name of medication,
 dose,
 route of administration, and
 Frequency
 It is common to write orders, first
 for any medications that are given for condition
necessitating hospitalization, then
 orders for any medications taken before
hospitalization that need to be continued, and then
 orders for any symptomatic medications

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Medications cont’d.
 Symptomatic medications are those that may or may not
be needed
 During a hospitalization, pts. experience sleeplessness,
constipation, pain, and nausea with such frequency that orders
are typically written at time of admission so that meds are
available to treat these symptoms if they develop

 Not only will these orders reduce discomfort for patient they
will also prevent nursing staff from having to call a prescriber
at 2:00 a.m. to request a sleep aid

 These meds would be ordered on a prn basis and are given only
as requested by pt. you always want to include indication for
giving the prn medication

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Medications cont’d.
 For example An order written as morphine 2 mg IV prn is
open for interpretation
 Although nursing staff would recognize morphine is a narcotic
analgesic and would know that it is given to relieve pain the
order is ambiguous
o Instead, it should be written with specific dosing, frequency,
and indication instructions, such as morphine 2 mg IV q2h
prn pain
• This prevents med. from being admin. for reasons other than
pain and establishes a safe time frame in which the med. may
be admin.
 A specific dose should always be ordered, rather than a range of
dosing such as morphine 2–6 mg IV q2-3h prn pain (incorrect)
this helps prevent inappropriate administration of the medication

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Procedures
 Many routine procedures are part of a pt’s daily care
may seem intuitive they should be performed
 However, writing an order for such procedures as daily
catheter care, wound or ostomy care, and dressing
changes provides justification for performing these
procedures and allows hospital to charge for necessary
supplies

 Order should specify how frequently procedures should


be carried out

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Labs (and other diagnostic studies)
 It may be necessary to monitor certain
laboratory values or obtain diagnostic studies as
part of a patient’s care
For example,
 When a pt. is on an anticoagulant medication
you monitor bleeding time
 If a patient develops fever and a cough, you might
order a chest x-ray (CXR)

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Labs cont’d.
You should always have a rationale for ordering
lab or other diagnostic studies
For example,
 If a pt. had surgery but had very little intraoperative
bleeding it is unnecessary to order H&H
(hematocrit and hemoglobin) qam you would not
expect values to change b/c there was little blood loss

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Labs cont’d.
 When ordering radiographic studies
indication for study should be included, not only
to aid radiology staff in interpreting study, but
also to establish relevance of the study to pt’s
overall car
 An example is AP (anteroposterior) & lateral CXR to
R/O atelectasis

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Special instructions
 Rationale for special instruction orders is to
ensure that nursing staff informs provider of
changes in a patient’s condition that may
require some intervention
 For example, results of glucose monitoring above or
below a certain level may require withholding,
increasing, or decreasing insulin doses
o You would write an order to Notify Dr. XX if blood sugar is
<100 mg/dL or >350 mg/dL

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Special instructions cont’d.
 If a patient was admitted 2 days ago for AMI
and now has new onset of atrial fibrillation
you want to be alerted to that fact
 You should never assume that nursing staff will
automatically notify you of such developments
o As a general rule, they probably would; however, responsibility
of managing changes in pt’s condition rests on the attending
medical staff—not nursing staff—and you can only manage
what you are aware of
o Writing special instruction order protects you as a clinician and
helps to ensure best treatment for patient

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So, to write complete Admit Orders,
remember…one of these 3 mnemonics
AD CAVA DIMPLS ---Or--- ADC VANDALISM ---Or--- ADCA VAN DIMLS + D
o Admit, o Admit to o A Admit to
o Diagnosis, o Diagnosis o D Diagnosis
o Condition, o Condition o C Condition
o Activity, o Vitals o A Allergies
o Vital signs, o Allergies o V Vital signs
o Allergies, o Nursing orders o A Activity
o Diet, o Diet o N Nursing orders
o Interventions, o Activity o D Diet
o Medications, o Labs o I IV orders
o Procedures, o IV fluids o M Medication orders
o Labs o Special studies o L Lab and other orders
o Special instructions o Medications o S Special orders
+
o D Discharge planning

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THE END

See next slide for links to tools and resources for further study.

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Tools & resources for further study:
Companion Notes
The “How To” of Clinical Wards Write-ups.pdf, includes:
• Admission H&P
• Admit Orders
• Admit Notes
• Progress Notes
• Procedure Notes
Books
Le T, Bhushan V, Yeh JS. First Aid for the Wards, 5th Ed. New York:
McGraw-Hill, 2013.
McDonough, K. , Larson E. Manual of evidence-based admitting orders
and therapeutics. 5th Ed. Philadelphia: Saunders-Elsevier, 2007.
Sullivan D. Guide to clinical documentation, 2nd Ed. Philadelphia: F. A.
Davis Company, 2012.

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