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13 Cards in this Set
- Front
- Back
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what is NOT included in an admit note with IS included in HP
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no negs no ROS that arent pertinent
**shoudl be about 1 page long |
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what are the sections included in an admit note
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CC: breif, pts own words
HcCC: include where pt came from PMH: + and pertinent - PSH: + ALL: food, latex, adhesive MEDS: PRIOR to hospitalization Social: occupation, travel, hobby, religious restriction, living will, EtOH, TOB, drug FAM: ROS: + and pert - PE: gen, vitals, HEENT, heart, lung, abd, ext LABS/Xray ASSESSMENT: # importance Plan: Admit Orders: ADC VAAN DISSEL |
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what goes on admit orders
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DADC VAAN DISSEL
Date/Time Admit: admit to --dept-- to the care of Dr___ Dx: must be billable, cant be a RO dx Condition: stable, guarded, criticle Vitals: how often, be specific (q shift, q 4 hours while awake, call HO if BP >180/90. routine is at admit and q8 hrs. specifiy if you want pulse ox Activity: up for meals, bedside commode etc ALLERGIES: food, meds, latex, adhesive Nursing: change dressing, respiratory- suction PRN, postural changes, can put orders here like call HO if BP >180 etc. bedside glucose stick Diet: Mechanical consitancy, content (heart diet, In/Out: IV orders go here, write type amt, rate. also how often you want i/o recorded Specific Drugs: tx pts, Symptomatic drugs: PRN pain, constipation, sleep meds. pt can resume own BC from home Extras: specialist consults, respiratory therapy, PT, social services Labs/Xrays: be specific Standardized order sets: |
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what is the appropriate dx for an admit order
1. RO MI OR 1 Chest pain, RO MI |
Chest pain, RO MI
MUST be billible for admit, CANOT be a RO |
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where in the admit note does it say what the pt can do, bathroom, walking, eating
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activity
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what are some examples of the mechanical consistency of food, what about content
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consistency: ice chips, sips and chips, clear liquid, full liquid, soft, purreed, mechanical gound, thick liquids
content: 1500 cc fluid restirction, low fat, low carb, low salt, low protein, 2000ADA, cardiac, renal, etc or can be regular diet, NPO past midnight for preop pt |
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admit orders
ADC VAAN DISSEL |
date time
admit to--- Condition-- Vitals Activity Allergies Nursing Diet In/Out Specific Meds Symptomatic meds Extras Lab/x ray |
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how are IV fluids written
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IV NS 1000cc @ 100cc/hr
IV 1/2NS @ 125cc/hr x 24 hrs Bolus 250CC NS IV, followed by NS drip TKVO |
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what is this used for
D5 1/2NS NS LR addatives Infusion rate |
D5 1/2NS: dextrose. hypotonic to plasma. used as maintaince fluid
NS: normal saline. isotonic, volume/Na replacement LR: lactated ringers, isotonic. NaCl + K, Ca, Lactate. volume replacement in surgical pts. not for pts with liver damage Additives: 20meq/L KCL to replace K, NOT used in renal pts Infusion rate: determined by the degree of volume depletion |
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is D5 or NS used to maintain fluid, what about to replace fluid. what about LR
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D5- maintain
NS- volume replacement LR- volume replacement in surgical pts (added K, Ca, Lactate) NOT for pts with renal damage |
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where in teh admit note are you really specific so you dont get called in teh middle of the night
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EVERYWHERE
symptomatic meds: pain, stool, sleep, anxiety SIGN YOUR ADMIT NOTE |
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where do consults go in admit note
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extras
dADC VAAN DISSEL |
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KVO
PR TED |
keep vein open (IV order)
per rectum thromboembolytic deterrent (stockings) |
