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How to Write Orders. Shruti Kant, MD Sonya Aikels, DO Pediatric Chief Residents July 2, 2008. Admission Orders. ADC VANDALISM Admit to peds service under Dr. ___ and residents (inpatient/observation) Diagnosis Condition – good/fair/critical Vitals – q ___ hours Allergies

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How to write orders l.jpg

How to Write Orders

Shruti Kant, MD

Sonya Aikels, DO

Pediatric Chief Residents

July 2, 2008


Admission orders l.jpg
Admission Orders

  • ADC VANDALISM

  • Admit to peds service under Dr. ___ and residents (inpatient/observation)

  • Diagnosis

  • Condition – good/fair/critical

  • Vitals – q ___ hours

  • Allergies

  • Nursing – I/O, daily wt, suctioning, neurochecks, reflux precautions, sz precautions etc


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Admit Orders (cont)

  • Diet

  • Activity – bed rest, out of bed to chair etc

  • Labs/imaging

  • IV fluids

  • Medications

  • Consults

  • Instructions


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Medication Orders

  • Write pt’s wt and allergies on order sheet

  • Amount and route of administration

  • Frequency of administration

  • Always check dosing!!!

  • Use LexiComp or Harriet Lane only to check dosage

  • Write dosage (mg/kg/dose or day) for every order


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Medication Orders (cont)

  • Always have a calculator!!

  • Must write PRN for as needed medications

  • Qualify PRN orders

  • No trailing zeroes (eg 1.0mg)

  • Always write preceding zeroes (eg 0.1mg)

  • Be specific with what you want done

  • If in doubt call the pharmacist or the nurse!


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Medication Orders (examples)

  • Tylenol 50mg q4 hrs prn (15mg/kg/dose)

    • Route not given

    • Prn specification

  • Ceftriaxone 100mg IV q day

    • Dosage not written

  • Novolog 5.0 units SQ q am

    • Trailing zero


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Abbreviations

  • Examples

    • QID/TID/QD

    • Cc

    • MS/MSO4

    • U

  • Look at list on order sheets

  • If in doubt, write it out!!


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Discharge Orders

  • D/C all lines

  • Discharge home with _____

  • Discharge diagnosis

  • Condition

  • Activity

  • Diet

  • Medications

  • Follow up – PCP and specialists

  • Special instructions for parents



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Scenarios

  • 14 d/o female with temp 100.8 ®

  • 6mo male with dehydration due to AGE

  • 12 y/o male, known asthmatic s/p acute exacerbation to go home on albuterol and pulmicort


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