DATE / TIME PROVIDER INITIALS PHYSICIAN ORDERS

Transcription

1 If appropriate for this patient, please consider the following order sets: Heart Failure Addendum #609; Acute COPD #789, Glycemic Control - Insulin Infusion #824, Glycemic Control - Subcutaneous Addendum #825, Mild/Moderate Alcohol Withdrawal #822, Severe Alcohol Withdrawal (FOR ICU/PCU ONLY) #823, Alcohol Withdrawal #935, Patient Controlled Analgesia (PCA) physician order #564 How to Determine Observation versus Inpatient Status A. Preamble: Ultimately, the Accepting Physician will determine whether the patient is placed in Observation or admitted to the Hospital. Nonetheless, the ED Provider, on the Bed Placement Slip and on the Transition Orders, designates Observation or Inpatient status. B. General Principles: Observation versus Inpatient 1. Choice of Observation versus Inpatient Observation is ideal for anticipated short length of stay (<24 hours) for symptomatic treatment o Co-morbidities might sway one to Observation instead of Discharge o In general about 70-80% of cases are expected to be discharged after the period of observation, with the converse converted to Inpatient o Example, SOB associated with exacerbation of Chronic CHF o Example, Abdominal pain, possible appendicitis Inpatient is ideal for diagnoses and severity typically associated with longer LOS (>24 hours) and for which there are DRGs o Co-morbidities might sway one to Inpatient instead of Observation, e.g. Diabetes o Example, Right Middle Lobe Pneumonia with Pulse Ox RA 90% o Example, Abdominal pain, acute surgical abdomen 2. Allowable changes after the patient is placed in the Hospital: Observation to Inpatient is OK Inpatient to Observation is very problematic If in doubt, place in Observation. This will assist with the identification for additional review of appropriateness of status. C. Suggested Process 1. ED Provider Speaks to Accepting Provider (FIT), presents the case, and asks FIT for the preferred Patient Status: Observation versus Inpatient 2. ED Provider fills out Bed Placement Slip and Transition Orders and orders Observation or Inpatient a. If uncertain and FIT wasn t sure, use General Principles above, and, if in doubt, i. Speak to UR person, if available, for guidance. ii. Order Observation and FIT can change to Inpatient, if necessary, after complete assessment. b. If placed in Observation, list symptoms or end points to observe for 3. FIT Provider (or Accepting Physician) writes General Medical orders (#049) a. FIT Provider fills out page one of General Medical orders and selects Inpatient or Observation D. Important: 1. For Observation status, must list symptom(s) or end points to observe for 2. For admission, a. Must establish Medical Necessity, e.g., Right Lung Opacity consistent with Pneumonia instead of Possible Pneumonia b. Be definitive and not vague c. List co-morbidities Page 1 of 13

2 General Level of Care (Single Response) ( ) Admit to Inpatient Diagnosis: Required Expected length of stay (days): Required Certification: I reasonably expect the patient will require inpatient services that span a period of time over two-midnights. (See Rationale Section in the order for options) Additional documentation will be found in progress notes and admission history and physical. Must be completed by Physician for Inpatient Admissions: Rationale for Inpatient Admission: Required Plans for post hospital care: See Discharge Summary/ Progress Note Level of Care: Required ( ) Refer to Observation Diagnosis: Required Monitor for: Required Notify provider when: Required Level of Care: Required SAH, SCH, SFH, SJMC & Highline Code Status (Single Response) ( ) Full code This code status was determined by: Required ( ) Full treatment WITH intubation but WITHOUT ACLS This code status was determined by: Required ( ) Full treatment WITHOUT intubation and WITHOUT ACLS This code status was determined by: Required ( ) Comfort Care This code status was determined by: Required Harrison Code Status (Single Response) ( ) Full code This code status was determined by: Required ( ) Full treatment WITH intubation but WITHOUT ACLS This code status was determined by: Required ( ) Full treatment WITHOUT intubation but WITH ACLS This code status was determined by: Required ( ) Full treatment WITHOUT intubation and WITHOUT ACLS This code status was determined by: Required ( ) Comfort Care This code status was determined by: Required Isolation Orders [ ] Contact Isolation, Continuous, Starting today [ ] Droplet Isolation, Continuous, Starting today [ ] Airborne Respirator Isolation, Continuous, Starting today [ ] Airborne Respirator, Contact, Droplet Isolation, Continuous, Starting today [ ] Neutropenic precautions, Continuous, Starting today [ ] Contact Enteric Isolation, Continuous, Starting today Page 2 of 13

3 Diet [ ] Diet NPO Diet effective now, Starting today NPO Except: [ ] Diet General Diet effective now, Starting today Select/Nonselect: Required Additional Modifiers: Viscosity/Liquids: Texture: Fluid Restriction / day: Supplements: [ ] Diet Cardiac Diet effective now, Starting today Select/Nonselect: Required Additional Modifiers: Viscosity/Liquids: Texture: Fluid Restriction / day: Supplements: Total Calories: [ ] Diet Diabetic Diet effective now, Starting today Diet, Diabetic: Select/Nonselect: Required Additional Modifiers: Viscosity/Liquids: Texture: Fluid Restriction / day: Supplements: Calories: [ ] Diet Liquid Diet effective now, Starting today Diet: Clear/Full Required Additional Modifiers: Viscosity/Liquids: Activity General [ ] Activity as tolerated, Until discontinued, Starting today [ ] Bed rest, Until discontinued, Starting today [ ] Bathroom privileges, Until discontinued, Starting today [ ] Up with assistance, Until discontinued, Starting today [ ] Fall precautions, Continuous, Starting today, Patient is fall risk Vital Signs [X] Frequent vital signs Indication: Q15 minutes x (# of occurrences): Q30 minutes x (# of occurrences): Q1 hour x (# of occurrences): 4 Q2 hours x (# of occurrences): Q4 hours x (# of occurrences): Then: Per unit routine Until discontinued, Starting today Page 3 of 13

4 [ ] Neuro checks, Now then every 4 hours, Starting today Indication: Q15 minutes x (# of occurrences): Q30 minutes x (# of occurrences): Q1 hour x (# of occurrences): 4 Q2 hours x (# of occurrences): Q4 hours x (# of occurrences): Then: Per unit routine Cardiac Monitoring [ ] Cardiac monitoring, Until discontinued, Starting today Notify Provider [X] Notify provider, Until discontinued, Starting today Pulse greater than: Respiratory rate less than: Respiratory rate greater than: Temperature greater than (Celsius): Urine output less than (ml/hr): Systolic BP greater than: Systolic BP less than: Diastolic BP greater than: Diastolic BP less than: Other: Of patient arrival to unit. Call attending on record. Nursing Treatment [ ] May be transported without RN or monitor, Until discontinued, Starting today [ ] Insert retention catheter [ ] Insert Foley catheter, As needed, Starting today, Insert as needed for inability to void or feelings of discomfort or distention. Initiate Medical Staff Approved Urinary Catheter Protocol., Post-op [ ] Urinalysis with culture, if indicated, upon insertion As needed, Starting today For 2 Occurrences Obtain a UA-R upon insertion and repeat UA-R prior to 48 hours post-insertion., Post-op [ ] Discontinue catheter when patient able to sit up on bedside., Once, Starting today Post Op Day: [X] Occult blood x 1, stool Once, Starting today Times 3 stools. [ ] Oxygen therapy, Continuous, Starting today O2 Delivery Method: Required Titrate to saturation of: 92% Indications for O2: Hypoxemia Indicate LPM/FiO2: Page 4 of 13

5 Inpatient Consults [ ] Inpatient consult to Cardiology Reason for Consult? [ ] Inpatient consult to Gastroenterology Reason for Consult? [ ] Inpatient consult to General Surgery Reason for Consult? [ ] Inpatient consult to Infectious Diseases Reason for Consult? [ ] Inpatient consult to Neurology Reason for Consult? [ ] Inpatient consult to FIT Hospitalist Reason for Consult? [ ] Inpatient consult to Sound Hospitalist Reason for Consult? [ ] Inpatient consult to Group Health Hospitalist Reason for Consult? [ ] Inpatient consult to Pulmonology Reason for Consult? [ ] Inpatient consult to Palliative Care Reason for Consult? Labs Chemistry [ ] Basic metabolic panel Morning draw, Starting today For 1 Occurrences Hematology [ ] CBC and differential Morning draw, Starting today For 1 Occurrences [ ] Hemoglobin and hematocrit, blood Every 4 hours, Starting today For 3 Occurrences Cardiac Enzymes [ ] Troponin I - 3, 6, 12 hour timed study [ ] Troponin I Q3 hours, Starting today For 2 Occurrences 3 and 6 hours after the first set of enzymes. [ ] Troponin I In 12 hours, Starting today For 1 Occurrences 12 hours after the first set of enzymes. [ ] CK isoenzymes - 3, 6, 12 hour timed study [ ] CK total and CKMB Q3 hours, Starting today For 2 Occurrences 3 and 6 hours after the first set of enzymes. [ ] CK total and CKMB In 12 hours, Starting today For 1 Occurrences 12 hours after the first set of enzymes. Page 5 of 13

6 Microbiology [ ] MRSA PCR screen Once, Starting today Add contact precautions, if required, per protocol. Imaging Imaging - Chest [ ] MRI angiogram head with contrast, 1 time imaging, Starting today For 1 Reason for Exam: Required Is the patient pregnant? What is the patient's sedation/anesthesia requirement? No Sedation Reason for Exam (USE SIGNS AND SYMPTOMS): Transport Mode: Bed [ ] MRI angiogram neck with contrast, 1 time imaging, Starting today For 1 Reason for Exam: Required Is the patient pregnant? What is the patient's sedation/anesthesia requirement? No Sedation Reason for Exam (USE SIGNS AND SYMPTOMS): Transport Mode: Bed [ ] NM lung scan ventilation and perfusion imaging, 1 time imaging, Starting today For 1 Reason for Exam: Required Is the patient pregnant? Reason for Exam (USE SIGNS AND SYMPTOMS): Transport Mode: Bed [ ] Echocardiogram 2D Complete, 1 time imaging, Starting today Where should test be performed? Reason for exam: Required Reason for Exam (Signs and Symptoms): Transport Mode: Bed [ ] Echocardiogram 3D Complete, 1 time imaging, Starting today Where should test be performed? Reason for exam: Required Reason for Exam (Signs and Symptoms): Transport Mode: Bed IV Fluids IV Fluids [ ] Saline Lock and Flush Panel [ ] sodium chloride 0.9 % syringe 10 ml, IntraCatheter, Every 8 hours, [ ] Saline lock IV, Continuous, Starting today [ ] sodium chloride 0.9% (NS) infusion 100 ml/hr, IntraVENous, Continuous Dose: Required Page 6 of 13

7 Medications Other Medications [ ] albuterol sulfate 2.5 mg/3 ml (0.083 %) nebulizer solution 2.5 mg, Nebulization, Every 4 hours PRN, wheezing, [ ] methylprednisolone 10 mg/ml IV syringe IntraVENous, for 15 Minutes, Every 6 hours Dose: Required Glucose Management [ ] Hemoglobin A1c Once, Starting today [ ] Blood Glucose Panel [ ] POCT glucose, Every 4 hours, Starting today For 1 Days [ ] POCT glucose, Every 6 hours, Starting tomorrow [ ] Hypoglycemia Protocol [ ] Hypoglycemia Protocol (Blood glucose less than 70 mg/dl), As needed, Starting today, 1. If patient awake and able to take PO-give 4 oz of clear regular soda (i.e. Sprite) 2. If patient awake and unable to take PO-give 25 ml 50% dextrose in water (D50W) IV push 3. If patient obtunded (due to hypoglycemia)-give 50 ml 50% dextrose in water (D50W) IV push 4. Recheck blood glucose in 15 minutes. If blood glucose less than 70 mg/dl, repeat above treatment. Recheck blood glucose every 30 minutes until greater than or equal to 80 mg/dl. 5. If glucose remains less than 70 mg/dl after 2 doses of soda/dextrose, then notify provider [ ] dextrose 50 % IV ml, IntraVENous, As needed, low blood sugar, see admin instructions 1. If patient awake and unable to take PO-give 25 ml 50% dextrose in water (D50W) IV push. 2. If patient obtunded (due to hypoglycemia)-give 50 ml 50% dextrose in water (D50W) IV push. [ ] Insulin Regular Correction Scale (Novolin R) (Single Response) Page 7 of 13

8 CHOOSE ONE ( ) insulin regular (NOVOLIN R) injection (LOW DOSE SUB-Q SCALE) ( ) insulin regular (NOVOLIN R) injection (MEDIUM DOSE SUB-Q SCALE) 2-10 Units, SubCutaneous, As needed, high blood sugar If fingerstick blood glucose over 180 mg/dl for 2 consecutive checks increase correction insulin scale to next higher dose. If NPO check blood glucose every 6 hours PRN Reason: Required Blood Sugar [mg/dl] Low Dose - Total Daily Dose Under 40 Units/Day units units units units Over 350-Notify MD 10 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: MEDIUM OR HIGH) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Go to Glucose Management in orderset and order Sliding Scale Insulin order for patient condition to get correct scale for admin instructions. Will this be administered via an insulin pump? 3-15 Units, SubCutaneous, As needed, high blood sugar If fingerstick blood glucose over 180 mg/dl for 2 consecutive checks increase correction insulin scale to next higher dose. If NPO check blood glucose every 6 hours PRN Reason: Required Blood Sugar [mg/dl] Medium Dose - Total Daily Dose Units/Day units units units units Over 350-Notify MD 15 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: LOW OR HIGH) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Go to Glucose Management in orderset and order Sliding Scale Insulin order for patient condition to get correct scale for admin instructions. Will this be administered via an insulin pump? Page 8 of 13

9 ( ) insulin regular (NOVOLIN R) injection (HIGH DOSE SUB-Q SCALE) [ ] Insulin Aspart Correction Scale (Novo Log) (Single Response) CHOOSE ONE ( ) insulin aspart (NovoLOG) injection ( LOW DOSE SUB-Q SCALE) 4-18 Units, SubCutaneous, As needed, high blood sugar If fingerstick blood glucose over 180 mg/dl for 2 consecutive checks increase correction insulin scale to next higher dose. If NPO check blood glucose every 6 hours PRN Reason: Required Blood Sugar [mg/dl] High Dose - Total Daily Dose Over 80 Units/Day units units units units Over 350-Notify MD 18 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: LOW OR MEDIUM) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Go to Glucose Management in orderset and order Sliding Scale Insulin order for patient condition to get correct scale for admin instructions. Will this be administered via an insulin pump? 2-10 Units, SubCutaneous, As needed, high blood sugar If fingerstick blood glucose over 180 mg/dl for 2 consecutive checks increase correction insulin scale to next higher dose. If NPO check blood glucose every 6 hours Blood Sugar [mg/dl] Low Dose - Total Daily Dose Under 40 Units/Day units units units units Over 350-Notify MD 10 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: MEDIUM OR HIGH) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Go to Glucose Management in orderset and order Sliding Scale Insulin order for patient condition to get correct scale for admin instructions. Will this be administered via an insulin pump? Page 9 of 13

10 ( ) insulin aspart (NovoLOG) injection (MEDIUM DOSE SUB-Q SCALE) ( ) insulin aspart (NovoLOG) injection ( HIGH DOSE SUB-Q SCALE) 3-15 Units, SubCutaneous, As needed, high blood sugar If fingerstick blood glucose over 180 mg/dl for 2 consecutive checks increase correction insulin scale to next higher dose. If NPO check blood glucose every 6 hours Blood Sugar [mg/dl] Medium Dose - Total Daily Dose Units/Day units units units units Over 350-Notify MD 15 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: LOW OR HIGH) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Go to Glucose Management in orderset and order Sliding Scale Insulin order for patient condition to get correct scale for admin instructions. Will this be administered via an insulin pump? 4-18 Units, SubCutaneous, As needed, high blood sugar If fingerstick blood glucose over 180 mg/dl for 2 consecutive checks increase correction insulin scale to next higher dose. If NPO check blood glucose every 6 hours Blood Sugar [mg/dl] High Dose - Total Daily Dose Over 80 Units/Day units units units units Over 350-Notify MD 18 units IF PATIENT IS ADVANCED TO ANOTHER SLIDING SCALE (EX: LOW OR MEDIUM) DO NOT MODIFY THIS ORDER. DISCONTINUE ORDER. Go to Glucose Management in orderset and order Sliding Scale Insulin order for patient condition to get correct scale for admin instructions. Will this be administered via an insulin pump? Analgesia [ ] morphine 2 mg/ml injection 2-4 mg, IntraVENous, Every 1 hour PRN, severe pain Avoid use in renal dysfunction (serum creatinine greater than 2mg/dl or patient on dialysis) [ ] HYDROmorphone (DILAUDID) injection IntraVENous, For 7 Days, [ ] Tylenol Panel (PO/PR) "Or" Linked Panel [ ] acetaminophen (TYLENOL) tablet 650 mg, Oral, Every 6 hours PRN, mild pain, Temp > 38 C or F PRN mild discomfort/temperature greater than 38degrees C Page 10 of 13

11 [ ] acetaminophen (TYLENOL) suppository 650 mg, Rectal, Every 6 hours PRN, mild pain, temperature, For temperature greater than 38 C PRN mild discomfort/temperature greater than 38 degrees C Aspirin [ ] aspirin tablet 325 mg 325 mg, Oral, Daily, [ ] aspirin chewable tablet 81 mg 81 mg, Oral, Daily, [ ] aspirin suppository 300 mg, Rectal, Daily, [ ] Patient is allergic to Aspirin - Aspirin not given, Until discontinued, Starting today [ ] Patient takes Aspirin Every Day, Until discontinued, Starting today [ ] Aspirin not indicated for patient, Until discontinued, Starting today Antiemetics IV Number only those medications desired. The nurse will select #1 as the first medication to be given. If ineffective, #2 will be used next, and then #3, #4 etc. Number IV/IM Meds and Oral Meds separately. If orders chosen are not numbered, the nurse will contact the prescriber for clarification. [ ] ondansetron (ZOFRAN) injection 4 mg, IntraVENous, Every 4 hours PRN, nausea, vomiting Med choice: Administration Instructions Required [ ] metoclopramide (REGLAN) injection 5 mg, IntraVENous, Every 6 hours PRN, nausea, vomiting, for patients age 65 and over Do not give if sedated or within 2 hours of promethazine. Med choice: Administration Instructions: Required [ ] metoclopramide (REGLAN) injection 10 mg, IntraVENous, Every 6 hours PRN, nausea, vomiting Do not give if sedated or within 2 hours of promethazine. Med choice: Administration Instructions: Required [ ] promethazine (PHENERGAN) 25 mg/ml injection mg, IntraVENous, Every 4 hours PRN, nausea, vomiting, for patients age 65 and over Med choice: Administration Instructions Required mg / min via tubing of running IV. If no large volume IV mix with 10 ml NS & give over 2 minutes. VESICANT * Do NOT infuse in HAND or small veins * If INFILTRATES, follow site specific IV Extravasation Treatment Protocol Page 11 of 13

12 [ ] promethazine (PHENERGAN) injection mg, IntraVENous, Every 4 hours PRN, nausea, vomiting Med choice: Administration Instructions: Required mg / min via tubing of running IV. If no large volume IV mix with 10 ml NS & give over 2 minutes. VESICANT * Do NOT infuse in HAND or small veins * If INFILTRATES, follow site specific IV Extravasation Treatment Protocol Nicotine Replacement Therapy Nicotine Replacement therapy will be avoided if possible in patient with unstable acute coronary syndrome for 72 hours. After 72 hours if chest pain, arrhythmias, and/or blood pressure have stabilized, Nicotine replacement may be considered at ONE STEP below the calculated replacement dose. NOTE: 1/2 pack = 10 cigarettes The nicotine products listed below may be used as monotherapy or in combination therapy. Combination therapy should include a nicotine patch plus either nicotine gum or nicotine lozenges. Smoking History Recommended Starting Dose Step down therapy after initial nicotine Replacement for 6-7 weeks 10 Cigarettes per Day or less, past history Of cardiovascular disease, or weight under 45 kg Heavy smokers (More than 10 cigarettes/day Nicotine patch, 7mg Nicotine patch, 14 mg Nicotine patch, 21 mg Smokeless tobacco users, pipe Smokers or at patient request Nicotine Gum, 2mg Note to provider: Insulin requirements may change - monitor blood sugars. Topical Steroids and oral antihistamines may be recommended to treat less severe skin irritations. [ ] No Smoking while on nicotine replacement therapy, Until discontinued, Starting today [ ] nicotine (NICODERM CQ) patch 7 mg 1 patch, TransDermal, for 24 Hours, Daily Change skin site daily and do not reuse for one week. Discontinue patch and notify prescriber if patient develops severe rash, chest pain, irregular heartbeat, palpitations, nausea, or vomiting. If severe rash develops, contact pharmacist with order to change to nicotine (Nicorette) gum. [ ] nicotine (NICODERM CQ) patch 14 mg/24 hr 1 patch, TransDermal, for 24 Hours, Daily Change skin site daily and do not reuse for one week. Discontinue patch and notify prescriber if patient develops severe rash, chest pain, irregular heartbeat, palpitations, nausea, or vomiting. If severe rash develops, contact pharmacist with order to change to nicotine (Nicorette) gum. Page 12 of 13

13 [ ] nicotine (NICODERM CQ) patch 21 mg/24 hr 1 patch, TransDermal, for 24 Hours, Daily Change skin site daily and do not reuse for one week. Discontinue patch and notify prescriber if patient develops severe rash, chest pain, irregular heartbeat, palpitations, nausea, or vomiting. If severe rash develops, contact pharmacist with order to change to nicotine (Nicorette) gum. [ ] nicotine polacrilex (NICORETTE) gum 2 mg 2 mg, Buccal, As needed, smoking cessation Maximum = 24 pieces/24 hours Date/time Provider Printed Name Provider Signature Date/Time RN Signature Acknowledgement Page 13 of 13