Ugh, poop on this.
Admission orders is one of those things where you need to know what to put in, but because every hospital is different there will be different important things to add. Also, who adds what changes based on what type of hospital you are in. Sometimes the residents do all of it. Sometimes the attending does part of it and the residents do the rest. Sometimes the ED doctors do some of them. It really all depends. But as a resident, you need to know what is important on what to add during admission orders.
First things First…
You need to accept the patient. Whether your attending does that for you or not doesn’t matter. Communicating with the ED doctors about accepting or declining admission is important. Once you have established the admission (or observation) then you can move forward with the next steps.
Then you do your regular chart review of a new patient. Write down what you need to know about the patient from what is in the ED note and any past/prior visits. You’ll want vitals, what was done/found, what meds were given, etc.
Write down what you want to ask the patient that you don’t see in the chart review to help clarify as well. Then go and see the patient. You can start putting in some orders before hand, but mostly you’ll want to see the patient first.
Orders
After seeing the patient you need to put in orders. You can do this prior to staffing with your attending or you can wait until after. If you wait, I suggest calling right away.
Here are 3 mnemonics to help remember orders:
I personally go off the headers under the orders tab in MEDITECH to remember. Since I can’t find an effective picture online OR take a decent photo from my computer screen (my stupid work computer won’t let me screenshot UGH), I’ll write the order below.
- Consults
- Diet- regular, heart healthy, carb controlled (for diabetics), renal, full liquids, clear liquids, NPO, etc
- Labs- you’ll need to order what other tests you would like to investigate with AND maintenance labs for the following day (i.e. H/H vs CBC, BMP vs just an electrolyte).
- Meds- what you are ordering during their inpatient stay
- Nursing orders- includes SCD’s (compression devices/VTE prophylaxis), vitals, activity, shower privileges, home med lists, fall or seizure precautions, and any treatment clarifications
- Radiology- any and all imaging studies
- Rehab- this is for your PT, OT, and ST orders. If patient is above 65 they automatically should be getting at least PT. If your patient is struggling with household tasks or fine motor movements OT should be ordered.
- Respiratory therapy- Your respiratory medications will be ordered under medications. But here is for oxygen monitoring/weaning, or suctioning, etc.
- Med Req- I always do this last. I usually wait until the nurses are able to obtain the patient’s home medication list, review it, and place it in the chart. Then I can go in and re-order the medications that they take from home or hold what I don’t want them taking. If the patient happens to have their medication list or the bottles of medications with them when I am admitting them, I will just place this information in myself.
- Also during admissions, I will update any allergies, PMHx, SHx, Family Hx, and Social Hx into the chart.
- Oh, and don’t forget to add code status if that is your job to obtain and place! At my institution it is the admitting physician’s job (aka admitting resident) to verify with the patient and place in the order.
So yes, it can be a lot to remember. Some programs have prompts for you to help you remember. After a while you just remember what to do. At this point (7 months in) I remember most of what I need to. Anything that I forget I will usually remember after starting to type my note.
I know this is a short post and not the most helpful thing, but I do hope it helps give you some clarification. Remember, this will come with time and repetition. IF you are a medical student trying to learn what you need to put under plans, learning these orders and placing them under your diagnosis headings can be helpful in teaching you important management.
Cheers!
