Order Writing:
Writing orders is a basic skill that is learned early in the third year. The basics of patient care in the hospital are:
1.) History and physical
2.) Problem list
3.) Differential diagnosis
4.) Admission orders for patient care and appropriate labs and x-rays
5.) Formulating a diagnosis and treatment plan
6.) Daily review of the patient's status and response to treatment
7.) Daily orders based on the patient's status
8.) Discharge orders
Background Information:
The patient is a 76 year old male with nausea for 1 week. His only home medication is Vasotec (enalapril). His physical exam is
significant for signs of dehydration, a mid-abdominal mass and generalized weakness.
Step One: Admission
A specific order is needed for admission. Make sure you
document the date and time.
Step Two: Diagnosis
Indicate a general reason for admission, you may not
know the specific diagnosis yet.
Step Three: Patient's Condition
Condition status is highly subjective. Terms used to
describe a patient's condition are stable, unstable, serious
or critical. Generally if a patient is admitted to an
intensive care unit they are serious or critical.
Step Four: Vitals
Vitals (blood pressure, pulse, temp, ...) are usually
checked every shift (every 8 hours), but can be checked
as frequent as every hour depending on the patients
status.
Step Five: Diet
Diets vary from N.P.O. to regular with many variations
in between. Clear liquid, full liquid, soft, diabetic, low
residue, etc are a few examples.
Step Six: Activity
Activity levels can range from bed rest to up ad lib (no
restrictions).
Step Seven: IV
IV orders vary, leave out if no IV is needed.
Step Eight: Lab
List all requested labs here. Order a lab "stat" if you
want the results as soon as possible.
Step Nine: X-Ray
List the type and the reason for the x-ray.
Step Ten: Medication
Include new medications for treatment and any home
medications.
Daily Orders:
Daily orders are used to change any admission order or for further investigation or treatment.
Discharge Orders:
Discharge orders also have a specific format. They are used to instruct the patient, schedule appropriate follow-up and educate the
patient in discharge medication and diet.
Our patient was found to have a benign pancreatic pseudocyst from alcoholism and was feeling much better at the time of discharge.
The following are the discharge orders for this patient.
Background Information:
The patient is a 76 year old male with nausea for 1 week. His only home
medication is Vasotec (enalapril). His physical exam is significant for
signs of dehydration, a mid-abdominal mass and generalized weakness.
Our patient was found to have a benign pancreatic pseudocyst from
alcoholism and was feeling much better at the time of discharge.
Step One: Discharge to _____
A specific order is needed for discharge. You need to specify where the
patient is being discharged to - home, nursing home, board and care
home, etc.
Step Two: Diet
List the type of diet the patient should be following after being
discharged.
Step Three: Physical Activity
List the level of activity for the patient. Activity levels can range from
bed rest to no restrictions.
Step Four: Medication
List all the medications the patient will be on, not just the new
medications.
Step Five: Follow-up
List any follow-up visit the patient needs.
Practice Discharge order form:
Background Information:
The patient was found to have pneumonia in the left lower lobe. He was treated with IV Levaquin then was switched to oral Levaquin
250 mg po qd before discharge. He will need antibiotics for 6 more days after discharge. He should see Dr. Smith three weeks after
discharge with a chest X-ray that day. He was discharged on October 3rd at 9:00 am.