Download Admission Orders and Admit Notes

Admission Orders and Admit Notes
RONALD JANUCHOWSKI, D.O.
Based on an original presentation by Ronnie B. Martin, D.O., FACOFP-dist.
OBJECTIVES
 By the end of the presentation, the student should:
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Know the purpose of the admission note
Name the elements of the admission note
Know the key elements of admission orders
Be able to write admission orders for a patient
Admit Note
 Multiple purposes:
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Disposition, stabilization and acute treatment of patient
Guide to definitive treatment of patient
Protection of patient safety, autonomy, integrity, etc.
Provide information to other providers
 Needs to be thorough to advance treatment of the patient but it is not a life story
or a novel.
 Not intended to be a complete history or physical, rather an detailed abstract of
the patient’s condition and treatment.
Admission Orders:
 There are lots of mnemonics to help you remember how to write admission
orders:
 ADC VANDALISM
 ADC VAN DISSMAL (ADC VAAN DISSMAL)
 6 D’s
 Many can be modified and guide writing of Admission Note as well.
Admission Orders: Six D’s:
 Disposition: admit to service and attending, vitals on admission, weight daily, daily
I/O
 Diagnosis: CAD r/o M.I., mental status change, etc. Include secondary diagnoses
that affect patient and any differentials pending workup and patient status
(serious, guarded, stable, etc.)
 Diet: NPO, clear liquid, liberal, 1800 calorie, etc.
 Diagnostics: additional lab, x-ray, special procedures, consultations, etc.
 Drugs: treatment, maintenance, symptom relief, I.V., O2, treatments with
albuterol, etc.
 Danger: notify if not responsive, if B/P < 90, HR>140, T>102
ADC VANDALISM:
 Admit
 Diagnosis
 Condition
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Vitals
Allergies
Nursing procedures
Diet
Activity
Lab
I.V.
Special Studies
Medications
Admit Orders: ADC VAAN DISSEL
 Admit
 Diagnosis
 Condition
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Vital signs
Activity
Allergies
Nursing procedures
Diet
Intake and output
Specific drugs
Symptomatic drugs
Extras or special studies
Labs studies
ADC VANDALISM:
 Admit: service, attending , (floor and room if known). If you are house staff officer
responsible, should be noted along with contact information
 Diagnosis: in order of priority-primary and secondary conditions. If writing post
operative orders, include the procedure performed (i.e. status post cholecystectomy).
 Condition: stable, good, fair, poor, alert, none-responsive, etc.
 Vitals: “routine”, q shift (aka every 8 hours), q4hours, hourly times four then every 4
hours, etc. If you want special evaluations such as spirometer volume or wedge
pressure q4 hours, written here.
 Allergies: NKDA, or name allergy AND reaction (e.g., hives, anaphylaxis)
ADC VANDALISM:
 Nursing Procedures:
 Intake/output
 Foley catheter, Nasogastric tube drainage on suction or gravity,
surgical drains or hemovac’s, chest tubes
 daily weights
 Oxygen requirement, postural drainage, incentive spirometry,
suctioning, etc.
 Wound care or dressing change instructions, postural drainage,
 Elevate head of bed, seizure precautions, fall precautions
ADC VANDALISM:
 Diet: regular, Diabetic, soft, renal, NPO
 Activity: Up in chair, ambulate at liberty, turn every two hours, etc.
 Lab studies (serial studies – cardiac enzymes, INR, Hematocrits, etc.)
 IV Fluids: Orders include the type of IV solution and the rate at which it
is to be infused, i.e. NS at 100cc/hr.
 Special studies: CXR, head CT, renal angiogram, stress test, consultations, etc.
 Include scheduling and indications for procedure
 Includes consultations, co-management, etc.
ADC VANDALISM:
 Medications: name, dose, route, schedule, and indication.
 This includes all medications to be given on a specific schedule, for
instance, antibiotics, diuretics, cardiovascular drugs, etc.
 Includes medication for symptom relief here as well, pain, fever, cough,
S.O.B., etc.
 Add “danger” if indicated: Call if: systolic BP >200, HR >150,
mental status change, respiration < 12/min., temp. > 101, etc.
Patient Orders:
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Date and time of orders must be included for each set of orders or note written
Each order should be numbered
Use only approved abbreviations
You must sign all orders
 You should print your name and title first, then sign below
 When you are a student or resident, you first print the attending or supervising residents
name, then yours and sign below.
 All student orders must be co-signed by a senior resident or attending before they are legal
and will be carried out by nursing and other allied health professionals.
Types of Consultations:
 Consult: give an opinion and recommendations but not write orders or
assume care of patient.
 Consult and participate in care: give an opinion and write orders, provide care
concerning area of expertise.
 Consult and manage: give an opinion and manage the overall care of the
patient, writing orders for other consults, tests, etc.
 Consult and assume care of patient: take over total care of patient, you
relinquish care.
Admission Note:
 The note is an important part of the medical record that documents the patient's
status, reasons why the patient is being admitted for inpatient care to a hospital or
other facility, and the initial instructions for that patient's care.
 Synthesis and analysis of the H&P
Admission Note:
 Admission note includes initial impression of patients condition and working
diagnosis, subjective as well as objective findings (patients condition, lab results,
diagnostic testing done prior to admission), and treatment plans (consultations,
Rx, etc.), and physicians impression of the prognosis at the time of admission.
 Consider this an H&P lite
 Usually done by upper level or supervising physicians
Admit Note:
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Chief Complaint
HPI
Past Medical Hx.
Past Reproductive Hx.
Past Surgical and Trauma Hx.
Social Hx.
Family Hx.
ROS
 Medications
 Allergies
Admit Note:
 Physical Examination
 General condition
 Vital Signs
 PE by System head to toe
 Diagnostic Results available at
admission
 Impression
 Treatment Plans
Admission Note:
 Patient identifying information:
 Name, D.O.B., age, sex, Pt. ID number, room number, admission date, attending physicians,
service
 Date and Time
 Chief Complaint: Ex. “64 y/o Hispanic male with right-sided weakness and slurred speech."
 History of Present Illness: summarizes the history of C/C regarding duration, onset, severity
(pain scale), characteristics, changes, treatments and outcomes of treatment, previous
episodes or related complaints, etc.
 Includes:
 statement of overall health status (normal health male, etc.)
 positive and negative symptoms related to the chief complaint based on the differential diagnosis the
health care provider has developed
 May have components of ROS included here.
Admission Note:
 Past Medical History: chronic diseases and treatments, acute diseases requiring
extensive treatment or hospitalizations . Childhood diseases listed here if significant
(rheumatic fever, asthma, anemia, hepatitis, whooping cough, etc.)
 Reproductive History: may list here or in ROS. Menstrual history, PG, AB, births,
living, birth control, etc.
 Past Surgical and Trauma History: in-patient or out-patient surgeries and significant
injuries that required surgery or medical treatment
Admission Note:
 Medications; prescription, over the counter, herbal, natural medications,
vitamin and mineral supplements and birth control.
 Should try and obtain data on dosage and frequency of utilization, history of
previous medications that have been discontinued in recent patient history
and reason.
 Allergies: medications, foods, and environmental, (grass, trees, cats,
etc.). Often recorded as both NKA (no known allergies) and NKDA (no
known drug allergies) for medications to identify from other allergies
Admission Note:
 Social History: Occupation, diet pattern, exercise pattern, sexual history
(number, type of partners, etc.), tobacco utilization, dipping and
smoking (history if stopped), alcohol utilization, social or recreational
drugs (M.J., cocaine, tranquilizers, pain medications, etc.), recent travel.
 Family History: Age and health status of first blood relatives (mom, dad,
siblings, grandparents), causes of death, age of death, significant family
history of chronic disease (CVD, CAD, DM, COPD, RA, etc.)
Pertinent Review of Systems with Notation of
Significant Positives and Negatives:
 Constitutional—weight loss/gain, night sweats, appetite,
sleeping, etc.
 HEENT-visual change, diplopia, photophobia, hearing change,
tinnitus, dizziness, vertigo, dental disease, difficulty swallowing,
epistaxis, sinusitis, neck masses, pain, hair changes, traumatic
changes, TMJ clicks, etc.
 Integument: rashes, erythema, nail changes, masses, pruritus,
pigmentation
 Neurological: CN 2-12 function, DTR’s, vibratory function,
proprioception, extremity drift, Babinski, clonus, tingling,
numbness, weakness, seizures, cephalgia, LOC, memory
changes, cognation changes, falling, syncope, visual change, etc.
ROS:
 C/V: rate and rhythm disturbances, edema, uncontrolled blood
pressure, chest pain, exertional fatigue or pain, leg pain,
cramping, cold extremities
 Heme-lymph: edema, petechial rash, ecchymosis, hemarthrosis,
dizziness, weakness, anemia history, abnormal bleeding
 Pulmonary: persistent cough, SOB, fever or night sweats,
hemoptysis, orthopnea, dyspnea, wheezing, productive cough,
weight change,
 G.I.: changes in bowel habits, abdominal pain, nausea, vomiting,
hematemesis, hematochezia, masses or bloating, appetite
changes, weight gain or loss
ROS:
 Nephrology/G.U.: hematuria, burning, dysuria, flank pain, change in
blood pressure, edema
 Reproductive: menstrual changes, dysmenorrhea, dyspareunia,
impotency, change in libido, nipple D/C, changes in size, pain, mass, self
exams if performed, Last mammogram, last pap smear and results, any
LEEP procedures, history of STD’s, etc.
 Endocrine: heat or cold intolerance, hair or skin changes, weight
change, menstrual changes, libido changes, weakness, polyuria,
polyphagia, polydipsia, difficulty swallowing, voice change, night
sweats, joint or back pain
ROS:
 M.S.: arthralgia, weakness, swelling, joint pain, gait instability, back
pain, neuropathy, paresthesias, edema, ischemic pain, etc.
 Osteopathic: pain, radicular pain or somatic dysfunction, structural
changes, abnormal ROM, TART changes, history of treatment, etc.
 Behavioral/Psych: anxiety, insomnia, depression, personality changes
Physical Examination:
 A systematic examination generally starts at the head and finishes with
the extremities and spine.
 It includes observation, auscultation, palpation and percussion of the
main organ systems and specific tests for body systems such as
neurological examination, rectal examination, pelvic examination, ROM
testing for spine or joints, osteopathic examination, etc.
 Examination includes recording of vital signs, including temperature,
weight, height, blood pressure, heart rate, respiratory rate, O2
saturation, BMI
P.E.
 General: obese AA female , well nourished, well hydrated, alert and
oriented, mentation grossly intact, appears stated age
 Vital Signs: documented, note abnormals
 Skin: Skin is warm, dry, and intact. Normal tone and turgor, no rashes,
petechiae, purpura. Hair pattern is normal, no lesions or ulcerations noted.
No tattoos or piercings noted.
 Lymph Nodes: no abnormal nodes noted in anterior or posterior cervical
chains, auricular, occipital, supraclavicular, axillary, inguinal regions. No
dependent edema or lymphedema noted. No erythema present over lymph
drainage system.
P.E.
 HEENT: HEAD- NCAT (normocephalic/atraumatic), hair pattern is normal, no
rashes or abnormal nodes.
 Eyes: PERRLA. EOMI, no gaze deviation noted. No nystagmus, no ptosis.
Conjunctiva - non injected. Sclera anicteric, no corneal abrasions or ulcers.
Anterior and posterior chambers are normal, retina is without hemorrhage
or exudate, optic disc is normal without pulpal edema, vision is 20/20 to near
and far testing.
P.E.
 Ears: Normal appearance to pinna and canals, no abnormal creases or
perforations. No gouty tophi. No exudate or drainage. Tympanic membrane
intact and move freely, normal cone of light, no scaring, no erythema, no
bulging or retraction. Hearing is grossly intact.
 Nose: Septum-non deviated. Turbinate mucosa- pink, no ulcerations or
epistaxis, no purulent discharge. No hypertrophy or polyps. Sinuses nontender to palpation and percussion.
P.E.
 Mouth/throat: moist mucous membranes, no pharyngeal erythema /exudates,
teeth in good repair, gums without pyorrhea or evidence of erythema or
abscess. Bite intact. Tongue in midline, no graphic changes noted. Gag reflex
intact, uvula arises in midline. No dysphonia or dysphagia. No exudate or
lymphatic hyperplasia noted to pharynx. No TMJ clicks and normal ROM.
 Neck: supple. No JVD (jugular venous distention) or pulses paradoxes. Carotid
pulses equal bilateral; no bruits. No basilar bruits. ROM normal without
restriction. Trachea is in midline and moves freely. Thyroid is not enlarged, nonnodular or tender.
P.E.
 Chest: : CTA bilaterally without wheeze, rales or rhonchi. There is no
palatable thrill or fremitus. No echophonia. No dullness to percussion.
Chest moves symmetrically without retraction or restriction, normal A-P
diameter.
 CV: RRR (regular rate/rhythm) with normal S-1 and S-2. There is no S-3 or S4. There are no rubs, murmurs or gallops. The PMI (point of maximal
impulse) is in the 6th ICS in the midline. There is no lift or thrill noted.
 Breast: Symmetric; no palatable masses, no nipple D/C, no skin
retraction/dimpling. No axillary nodes
P.E.
 Abd: Soft, symmetrical, non-distended without striae or rash. There are normal
bowel sounds. No bruits, rushes or extra bowel sounds. no tenderness, G/R/R is
noted. No organomegaly or masses to palpation or percussion.
 Rectal: no hemorrhoids, no prolapse, no ulcerative lesions or rashes, no gross
bleeding, guaiac is negative. No masses to digital rectal examination.
Prostate/uterus is smooth, no masses. Mid-line sulcus of prostate is intact and
lobes are symmetrical. No pelvic masses are noted.
P.E.
 Pelvic: perineum , labia and introituses are normal without rash or lesions.
There is no cystocele or rectocele noted. Vaginal vault has normal rugae
without lesion or abnormal exudate or discharge. Urethra is normal. Cervix is
smooth without lesions, moves freely. Uterus is small, symmetrical and moves
freely. There are no abnormal masses or pain to bi-manual examination. The
tubes are soft and symmetrical, without masses or pain. The ovaries are small,
smooth, painless and move freely. No pelvic masses or fluid are noted.
 Osteopathic: Joints are intact and symmetrical with normal range of motion at
wrist, elbow, shoulder, ankle, knee and hip. Muscle tone is normal to palpation
without fibrotic or boggy changes noted. The spine is symmetrical with normal
ROM in F/E/SB/Rot. There is no scoliosis or kyphosis. No leg length, hips and
iliac crests asymmetry are noted. There are no TART changes noted to
palpation
P.E.
 Extremities: Intact and symmetrical. No erythema, effusion or edema is noted
to the joints. Muscle tone is normal, skin and hair pattern is normal. strength 5/5
in all extremities. Nail beds are pink, there is normal blanch and flush reaction.
DTR’s are ¾ and symmetrical upper and lower extremities. ROM is intact
without crepitance or clicks. Grip is symmetrical. No clonus or tremor is noted.
Dorsalis pedis, posterior tibia, radial, ulnar, pulses 2+ bilaterally.
 Neuro: A and O x 3 (place, person, time) and mentation is intact. Cranial Nerves
II-X intact. Reflexes-normal, 2/4 in all extremities. No muscle weakness.
Vibratory sense and sensation to light touch (hot/cold) intact. No Cerebellar
signs., negative Babinski, neg. Kernig’s sign, no clonus, no drift, no tremor.
Assessment and Plan:
 Diagnostic studies or lab results available at the time of
admission.
 Assessment and differential diagnosis impressions:
 Patients condition, impression, differential diagnosis under evaluation or
consideration, and prognosis assessment
 A listing of problems may be organized by priority or by organ system,
with specific planned actions associated with each item on the problem
list.
 Secondary diagnoses that are present but may (or may not) play a
contributing role to the current condition of admission
Assessment and Plan:
 Treatment plans
 Consultations
 Further Diagnostic studies
 Treatments and procedures (include surgery, OMT, etc.)
 Medications (oral, IV)
 Nutrition or special needs
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