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How to Write Orders - PowerPoint PPT Presentation


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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

How to Write Orders

Shruti Kant, MD

Sonya Aikels, DO

Pediatric Chief Residents

July 2, 2008

admission orders
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
admit orders cont
Admit Orders (cont)
  • Diet
  • Activity – bed rest, out of bed to chair etc
  • Labs/imaging
  • IV fluids
  • Medications
  • Consults
  • Instructions
medication orders
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
medication orders cont
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!
medication orders examples
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
abbreviations
Abbreviations
  • Examples
    • QID/TID/QD
    • Cc
    • MS/MSO4
    • U
  • Look at list on order sheets
  • If in doubt, write it out!!
discharge orders
Discharge Orders
  • D/C all lines
  • Discharge home with _____
  • Discharge diagnosis
  • Condition
  • Activity
  • Diet
  • Medications
  • Follow up – PCP and specialists
  • Special instructions for parents
scenarios
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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