General Medicine Admission Order Set – Sample Template



General Surgery Admission Order Set – Sample Template

Time: __________________ Date (yyyyy/mm/dd): _______/_____/_____

Admit to General Surgery

Attending physician: _________________________________________

Most Responsible Housestaff: ___________________ Pager: ________

Admitting Diagnosis: ________________________________________

Other Diagnoses: ___________________________________________

___________________________________________

Estimated Date of Discharge (yyyyy/mm/dd): _______/_____/_____

Allergies:_________________________________ ( no known allergies

CODE STATUS

❑ Full resuscitation

❑ Mechanical ventilation but no CPR

❑ No cardiopulmonary resuscitation

ISOLATION STATUS

❑ Do not isolate

❑ Contact isolation [e.g. C. Difficile, MRSA, VRE]

❑ Contact + droplet isolation

❑ Contact + airborne + negative pressure room [e.g. TB]

MONITORING

❑ Vital Signs (BP, HR, RR) every ____hours

❑ Temperature every ____ hours

❑ Monitor SaO2 every ____ hours

❑ Pain score every ____ hours

❑ Chart all fluid intake and output every ____ hours

❑ Hemovac drainage every ___ hours

❑ Capillary blood glucose every _____ hours

❑ Weight on admission: _________ kg

❑ Weigh: ( daily ( Other ______________

❑ Other: ___________________________

❑ Notify physician if: systolic BP less than 90 or greater than 160

HR less than 60 or greater than 110

SaO2 less than 85%

urine output less than ___ mL/hour

ACTIVITY

❑ Mobilize as tolerated

❑ Ambulate three times daily

❑ Up in chair ( daily ( for meals

❑ Bedrest ( elevate head of bed 30o

❑ Other: ___________________________

DIET

❑ Healthy heart diet

❑ Diet as tolerated

❑ No added salt

❑ Diabetic diet (________ kilojoules)

❑ Full fluids

❑ Clear fluids

❑ Sips to clear fluids

❑ Ice chips

❑ NPO

❑ Enteral feeds (specify name): ________________ at ____ mL/hr

❑ Other: ___________________________

INVESTIGATIONS

❑ CBC

❑ PTT, INR

❑ Creatinine ( Urea

❑ Glucose

❑ Electrolytes (K, Na, Cl, HCO3)

❑ Liver profile (AST, ALT, ALP, bilirubin)

❑ Amylase

❑ Urinalysis

❑ Culture: ______________________________________

❑ Other labs: ____________________________________

❑ ECG

❑ X-Ray: _______________________________________

❑ Daily portable chest X-Ray while chest tube in place

❑ CT Scan: _____________________________________

CONSULTATIONS (provide reason)

❑ Acute Pain Service: ________________________________________

❑ Community Care Access Centre (CCAC): _______________________

❑ Dietitian: _________________________________________________

❑ Discharge Planner: _________________________________________

❑ Internal Medicine: __________________________________________

❑ Occupational therapy (OT): ___________________________________

❑ Pharmacy: ________________________________________________

❑ Physiotherapy (PT): _________________________________________

❑ Respiratory therapy (RT): _____________________________________

❑ Social Work: _______________________________________________

❑ Speech/language therapy (SLP): _______________________________

❑ Wound care: _______________________________________________

❑ Other: ____________________________________________________

LINES, TUBES, DRAINS

❑ Saline lock

❑ Peripheral IV: Solution:_________ Rate:________

Add KCl: ( 20 mmol/L ( 40 mmol/L

❑ Central IV: Solution:_________ Rate:________

Additives:_________________________________

❑ Foley catheter to urometer

❑ Oxygen: ( nasal prongs at _________ L/min

( _____ % face mask

( Titrate 02 to keep SaO2 greater than 94%

❑ Nasogastric tube ( to straight drainage

( to suction at ______ cm H20

( flush with normal saline 20 mL q4h and PRN

( replace NG losses IV with normal saline + 20 mmol/L

KCl volume per volume every 8 hours

❑ Wound drain (number, locations): _____________________________

Empty drain every shift and record drainage

❑ Chest tube(s) ( to underwater seal drainage

( to suction at ______ cm H20

DVT PROPHYLAXIS

To be started post-op or pre-op if there is a delay of > 24 hrs to OR

❑ Heparin 5000 units SC ( BID or ( TID (cancer surgery, additional

thrombosis risk factors or weight > 90 kg)

OR (one of):

❑ Dalteparin 5000 units SC once daily

❑ Enoxaparin 40 mg SC once daily

❑ Tinzaparin 4500 units SC once daily

OR (if patient actively bleeding or at very high risk of bleeding)

❑ GCS ( IPC [for both, use continuously on both legs unless the patient is

walking or for bathing]

Provide reason(s) for this option: ________________________________

PAIN MANAGEMENT, ANTINAUSEA, SEDATION

❑ Postop PCA (see separate order sheet)

❑ Epidural (see separate order sheet)

❑ Acetaminophen ______mg PO/NG q _____h PRN (not to exceed 4,000 mg in 24 hr period)

❑ Morphine _________ mg IV / IM / SC q _____h PRN

❑ Morphine _________ mg PO q 3-4 h PRN

❑ Oxycodone ___________ mg PO q4h PRN

❑ Oxycodone/acetaminophen (Percocet() 1-2 tablets PO q4h PRN

❑ Tylenol #3 _____ tablets PO q6h PRN

❑ Other: ______________________________________________

❑ Other: ______________________________________________

❑ For nausea - dimenhydrinate (Gravol() 25-50 mg IV / NG / PO q4h PRN

❑ For nausea – ondansetron 4 mg IV q12h PRN

❑ Sedation: lorazepam ____mg QHS PRN

MEDICATIONS TAKEN PRIOR TO ADMISSION:

❑ Hold

❑ Continue the following:

o _________________________

o _________________________

o _________________________

o _________________________

o _________________________

OTHER MEDICATIONS

❑ Laxative or ( routine bowel routine

o Docusate Sodium (Colace() 200 mg ( qam ( BID

o Senokot ______ tablets qhs PRN

o Milk of magnesia 30 mL po qhs PRN

o Glycerin suppository qhs PRN

o Fleet enema once daily PRN

o Other: ____________________________________

❑ Antibiotic Therapy:

o Metronidazole 500 mg IV pre-op

o Cefazolin (Ancef() 1g IV 1 hour pre-op

o Cefazolin (Ancef() 1g IV q8h

o Gentamicin (1.5mg/kg)_______mg IV pre-op

❑ If patient has true penicillin allergy:

o Clindamycin 600 mg IV 1 hour pre-op

o Vancomycin 1g IV pre-op

o Vancomycin 1g IV q12h

OTHER

❑ Change wound dressings every _______

❑ Bowel Prep: ________________________

o _____________________________

o _____________________________

❑ Other: _____________________________________

❑ Other: _____________________________________

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