Order Writing

1. Order Writing

2. ADC VAAN DISML Essentials: Clarity Date, Time, Signature Appropriate Rank Re-evaluate

3. ADC VAAN DISML • Admit Order • Location • Attending Physician Order Writing “Admit Mr. Jones to 6B, monitored bed, for Dr. Frank”

4. ADC VAAN DISML • Diagnosis • Chief complaint or problem(s) “Diagnosis: Acute Coronary Syndrome” Order Writing

5. Good • Fair • Poor • Guarded • Critical Order WritingADC VAAN DISML = Condition “Condition: Stable” No anticipated complications; pt. Stable Pt. Is ill, may have complications Very ill pt., chronically or terminally ill, not very stable Very ill pt., clinical outcome not predictable Desperately ill, unstable patient

6. ADC VAAN DISML = Vital Signs (T, P, R, BP) • Patient’s condition dictates frequency • Special variables need orders • orthostatics, neuro status, pulse oximetry • Review daily • “Call” orders Order Writing “Vital signs q 4 hours. Call if P>100 or< 60, SBP>150 or<90”

7. ADC VAAN DISML = Activity • Restricted/Encouraged Bed rest Bed rest with bathroom privileges/bedside commode Up in chair/hall Walk with assistance - how often Up ad lib Order Writing “Bed rest. Up to bathroom with assistance”

8. ADC VAAN DISML • Allergies • Include what they are allergic to and what reaction they get Order Writing “Allergies: Penicillin - Hives and Wheezing”

9. Intake and Output • Daily weights • Patient positioning/turning • Wound care • Foley catheter, nasogastric tube • “Call” orders - e. g. pain, urine output Order WritingADC VAAN DISML= Nursing Instructions “1. Intake and Output 2. If patient develops chest pain, give 0.4 mg nitroglycerin s.l., obtain 12-lead EKG and call me stat on pager 1234”

10. Oral Nutrition - restricted or normal diet • diabetes, renal or liver disease • NPO for altered mental status, pre-surgical patients, some abdominal problems • If NPO, need order for alternative hydration and nutrition Order WritingADC VAAN DISML=Diet/Nutrition “Two gram sodium diet today, then n.p.o. after midnight”

11. Short term intravenous therapy • Electrolyte solutions • Long term intravenous therapy • parenteral or enteral nutrition ADC VAAN DISML = Diet/Nutrition

12. Be specific about composition, rate of administration and quantity • D5W - 5 % Dextrose in Water • D5½NS - 5% Dextrose in half normal saline • NS - Normal Saline • LR - Lactated Ringers solution • Example: “Infuse one liter of NS at 500cc/hour, then saline lock” • Request pumps when indicated Order WritingADC VAAN DISML=Intravenous Fluids “Place saline lock”

13. Imaging studies - X-ray, sonograms, CT’s • Cardiovascular Studies - EKGs, echocardiograms, dopplers • Neurologic studies - EMGs, EEGs • Provide explanations when appropriate • Communicate directly with consulting physician when possible, always in stat situations “1. Portable Chest X-ray 2. EKG, stat 3. Consult Dr. Stuart Frank regarding Acute Coronary Syndrome- I have notified him” Order WritingADC VAAN DISML=Special Studies and Consults

14. Dosage • Route of Administration • Be specific with prn orders • Review medications daily • Be specific when making changes. Cancel previous orders • If stat, communicate directly with nurse Order WritingADC VAAN DISML = Medications

15. “1. ASA 325 mg., p.o. now x 1 dose 2. Start intravenous nitroglycerin drip at 10 micrograms/min. Increase rate by 5 micrograms/min every 15 minutes until systolic BP is 110, or until chest pain is relieved. Call me if rate of 30 micrograms/min is reached, or if chest pain is not relieved 3. Infuse heparin bolus 5000 units intravenously and follow by heparin drip at 1000 units/hour 4. Metoprolol 50 mg. p.o. BID” ADC VAAN DISML = Medications

16. Be specific about blood product desired • packed cells, whole blood, platelets, cryoprecipitate • Clearly state how many units desired • Clearly state what you want done • Type and Cross order should precede transfuse order Type and Crossmatch Orders “Type and Cross 4 units of PRBCs. Transfuse two units now, each over 4 hours; Hold two units in blood bank”

17. Avoid orders for daily blood work • phlebotomy associated anemia not uncommon • Timing important for fasting levels, some drug levels Order WritingADC VAAN DISML =Laboratory Studies “1. CBC, Cardiac Enzymes, Troponin I, BMP, PT, INR, PTT stat 2. Repeat Cardiac enzymes and troponin q 6 hours x3 3. Repeat EKG q 6 hours x3 4. PTT 4 hours after heparin is started”

18. THANK YOU,Jane Jones, MSIII

19. Don’t forget to date and time all orders and notes!

20. Patient’s full name and DOB • Date • Rx • Drug Name…generic or trade name acceptable • Dosage • Quantity to be dispensed • Directions to patient • how many, how often, what route • how long? With meals? • Avoid “as directed” Prescription Writing

21. Number of refills • consider whether acute or chronic illness, abuse potential of drug, possibility of overdose • May substitute? • Generics are cheaper • Signature. DEA number for schedule II drugs. Prescription Writing

22. IU • Mistaken as "IV" (intravenous) or 10 (ten). • Write international unit(s) • MgSO4 • Misinterpreted as morphine sulfate, resulting in the wrong medication being administered. • Write magnesium sulfate • MS / MSO4 / MSO4 • Misinterpreted as magnesium sulfate, resulting in the wrong medication being administered. • Write morphine • Q.D. / QD / q.d. / qd • Mistaken for Q.O.D./ qod, resulting in an inappropriate dosing schedule. • Write daily • Q.O.D. / QOD / q.o.d. / qod • Mistaken for Q.D./qd, resulting in an inappropriate dosing schedule. • Write every other day • T I W • Misinterpreted as "three times a day" or "twice a week." • Specify days of the week • U / u • Mistaken as a zero or a four (4), resulting in overdose. Also mistaken for "cc" (cubic centimeters) when poorly written. • Write unit(s) • µg • Mistaken for "mg" (milligrams) when written, resulting in an overdose. • Write microgram(s) or mcg Avoid the Following Abbreviations