Download Order Writing Guide

ORDER WRITING
May 1, 2008
Orders are generally given in a specific sequence so as not to miss any critical item.
Some use simple memory hints like “bed, board, bowels, bladder, blood, biotics” to help
trigger an ordering sequence. Some like “AC/DC VAAN DIMILS” where A=Admission,
C=Condition/Code status, D=Diagnosis, C=Consults, V=Vital signs, A=Allergies,
A=Activity, N=Nursing, D=Diet, I=Input & Output record, M=Medications, I=IV fluids,
L=labs, and S=Specials (radiology/cardiology). Order sets are available on Cerner, listed
under specific diagnoses, and can help you avoid missing some critical issues like an
ACE inhibitor for CHF patients. A copy of the order sequence from Cerner is attached.
Many pocket books exist to help guide in this task. Listed below is a general guideline to
follow.
1.
Admit: to site (a room or floor like the ICU); to a specific doctor and/or
service
2.
Diagnosis primary (the main issue you have to deal with); secondary (other
pertinent problems that may influence length of hospital stay)
3.
Condition: usual description: “critical, poor, fair, good”
4.
Code status: choices include: no CPR, comfort measures only (CMO),
limited therapy (check off which ones like antiarrhythmics), full code
5.
Vital signs: frequency: every 8 h, TID, Q4h, etc. Do you want to be called?
If so give parameters or else it will be left to the discretion of the nurse: BP
(high [like over 160 systolic] or low [like under 90 systolic]); P (high or low);
T (high or low); R or RR (high or low)
6.
Monitor: (Can leave out if no monitoring is needed.) A. Monitored bed or
flex monitor; B. Pulse oximetry
7.
Allergies: drugs always listed; other critical allergies usually listed: latex,
tape, iodine, etc. Sometimes food also.
8.
Activity: up ad lib, up to chair (how often); ambulate (how often: “prn”, etc.);
bed rest with bathroom privileges, complete bed rest, non-weight-bearing
(right, left, total), etc.; turning frequency; special beds or mattress
9.
Patient care orders:
A. I & O
B. Stool count
C. Daily weights
D. Other
10.
Diet: multiple choices even gourmet foods! calorie restricted, salt restricted,
NPO, mechanical soft, thickened liquids, etc. A dietary consult often helps.
11.
Lines and tubes:
A. Foley catheter
B. Intermittent straight catheter
C. Rectal tube
D. Chest tube
E. Drains
F. Endotracheal tube care
12.
IV lines: injection cap, heparin lock (usually not ordered separately if IV
fluids ordered unless several lines needed); usually 2 lines for bleeding
patient; PICC line; central line; arterial lines are also included even though not
“IVs”
13.
Fluids: normal saline, 1/2NS, 1/4NS, D5W, lactated Ringers. etc.; if giving
blood products, always get the patient/power of attorney/closest relative to
sign permission form
14.
Hyperalimentation: must be ordered daily
15.
Restraints/Precautions: Restraints must be justified and ordered daily;
usually to stop falls or fall risk. Precautions to prevent falls, seizures, etc. also
listed
16.
DVT prophylaxis: subcutaneous heparin, sequential stockings, “TEDS”, etc.
17.
Laboratory tests:
A. Blood: BMP, BNP, CMP, CBC, ABG, tropinin, etc.
B. Stool: GUAIAC [note correct spelling], C.diff toxin, culture, etc.
C. Urine
D. Body fluids
E. Other
18.
Diagnostic tests:
A. EKG: repeat needed?
B. Radiographs: CXR, CT, MRI
C. Sonograms/Echos
D. Special labs: PFTs, EEG, EMG, ENG, etc.
E. Other
19.
Oxygen: titrate to a specific level; rate per nasal cannula, face mask, etc.
20.
Medications: on separate side of hand written order sheet: drug, dose, route,
frequency; if prn; use of home medications; etc.
21.
Consults:
A. Physicians
B. Social service
C. Physical therapy
D. Occupational therapy
E. Speech
F. Pharmacology
G. Ethics
H. Home care
I. Hospice
J. Other
22.
Special procedures:
A. Operating room: schedule
B. Cardiac
C. Radiologic
D. Other
23.
Respirator Care/ BiPAP
24.
Wound/cast care
25.
Devices: orthopedic hardware, etc.
26.
Oral orders/Student order
Generally oral orders must be signed within 24 hours; many institutions will
not accept oral orders from students; student orders
must be cosigned by residents or attendings before they are acted upon.
So, a lot to consider. After you do orders a few times, it will be easier to remember and
do rapidly.