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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