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ID

15769

Description

AAFP: Acute Mental Status Change Admission Order, Standardizes Admission Orders, Author: Robert M. Wiprud, MD The primary purpose of these Ordersets is to decrease unnecessary variability and to improve quality through standardized Admission Orders. Developed by the Scott & White Clinic at College Station, Texas. Copyright © 2006 American Academy of Family Physicians. Physicians may photocopy or adapt for use in their own practices; all other rights reserved. Wiprud RM. Providing consistent care with standardized admission orders. Fam Pract Manag. September 2006: 49-52 See http://www.aafp.org/fpm/2006/0900/p49.html This ODM Form includes the first section ("Acute mental status change admission order").

Link

http://www.aafp.org/fpm/2006/0900/p49.html

Keywords

  1. 6/13/16 6/13/16 -
Uploaded on

June 13, 2016

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License

Creative Commons BY-NC 3.0

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    AAFP: Acute Mental Status Change Admission Order

    AAFP: Acute Mental Status Change Admission Order

    Default Itemgroup
    Description

    Default Itemgroup

    Name
    Description

    Name

    Data type

    text

    Age of Patient
    Description

    Age

    Data type

    integer

    Alias
    UMLS CUI [1]
    C0001779
    Date of birth
    Description

    Date of birth

    Data type

    date

    Alias
    UMLS CUI [1]
    C0421451
    Patient Hospital No.
    Description

    Medical Record Number

    Data type

    text

    Alias
    UMLS CUI [1]
    C1301894
    Status
    Description

    Status

    Admission Status
    Description

    Status

    Data type

    text

    If Other, please specify:
    Description

    Status: Other

    Data type

    text

    Attending
    Description

    Attending

    Name of attending physician
    Description

    Attending physician

    Data type

    text

    Alias
    UMLS CUI [1]
    C2361125
    Phone number of attending physician
    Description

    Phone number

    Data type

    integer

    Admitting Diagnosis
    Description

    Admitting Diagnosis

    Acute Mental Status Change Associated Diagnosis
    Description

    Acute Mental Status Change Associated Diagnosis

    Data type

    text

    Condition
    Description

    Condition

    Condition
    Description

    Condition

    Data type

    text

    Code Status
    Description

    Code Status

    Data type

    text

    Allergies
    Description

    Allergies

    Allergies
    Description

    Allergies

    Data type

    text

    Alias
    UMLS CUI [1]
    C0020517
    Diet
    Description

    Diet

    Diet
    Description

    Diet

    Data type

    text

    If ADA, please specify amount of calories
    Description

    Diet: ADA specification

    Data type

    integer

    If other, please specify
    Description

    Diet: Other specification

    Data type

    text

    Activity
    Description

    Activity

    Activity
    Description

    Activity

    Data type

    text

    Nursing
    Description

    Nursing

    Vital signs with neuro every 4 hrs for 24 hrs then every shift
    Description

    Nursing: Vital signs with neuro every 4 hrs for 24 hrs then every shift

    Data type

    boolean

    Notify MD for: T > 101.5,Hr > 120, BP < 90/60 or > 180/110, decline in neurostatus, o2 sat < 92%
    Description

    Nursing: Notify MD for: T > 101.5,Hr > 120, BP < 90/60 or > 180/110, decline in neurostatus, o2 sat < 92%

    Data type

    boolean

    Pulse ox every 8 hrs nasal cannula/face mask to maintain o2 sat > 92%
    Description

    Nursing: Pulse ox every 8 hrs nasal cannula/face mask to maintain o2 sat > 92%

    Data type

    boolean

    I & O
    Description

    Nursing: I & O

    Data type

    boolean

    Medications (for aggressiv or psychotic behavior management) Composed of: 1) Acutely agitated and over 200 lbs without renal/hepatic impairment 2) Acutely/moderately agitated and under 20 lbs without renal/hepatic impairment 3) Mildly agitated with renal/hepatic impairment 4) Elderly/Frail
    Description

    Medications (for aggressiv or psychotic behavior management) Composed of: 1) Acutely agitated and over 200 lbs without renal/hepatic impairment 2) Acutely/moderately agitated and under 20 lbs without renal/hepatic impairment 3) Mildly agitated with renal/hepatic impairment 4) Elderly/Frail

    Acutely agitated and over 200 lbs without renal/hepatic impairment
    Description

    Acutely agitated and over 200 lbs without renal/hepatic impairment

    Haldol 10 mg PO/IM, Ativan 4mg PO/IM and Cogentin 1 mg PO/IM every 6 hrs prn; hold if BP < 100/60 mmHg OR
    Description

    Haldol 10 mg PO/IM, Ativan 4mg PO/IM and Cogentin 1 mg PO/IM every 6 hrs prn; hold if BP < 100/60 mmHg OR

    Data type

    boolean

    Geodon 20mg IM every 8 hrs prn; hold if BP < 100/60 mmHg
    Description

    Geodon 20mg IM every 8 hrs prn; hold if BP < 100/60 mmHg

    Data type

    boolean

    Acutely/moderately agitated and under 200 lbs without renal/hepatic impairment
    Description

    Acutely/moderately agitated and under 200 lbs without renal/hepatic impairment

    Risperdal 2 mg and Ativan 2 mg PO ever 6 hrs prn, OR
    Description

    Risperdal 2 mg and Ativan 2 mg PO ever 6 hrs prn

    Data type

    boolean

    Haldol 5 mg IM and Ativan 2 mg IM and Cogentin 1 mg IM every 4 hrs prn; hold if BP < 100/60 mmHg, OR
    Description

    Haldol 5 mg IM and Ativan 2 mg IM and Cogentin 1 mg IM every 4 hrs prn; hold if BP < 100/60 mmHg

    Data type

    boolean

    Geodon 20 mg IM every 8 hrs prn; hold if BP < 100/60 mmHg, OR
    Description

    Geodon 20 mg IM every 8 hrs prn; hold if BP < 100/60 mmHg

    Data type

    boolean

    Mildly agitated with renal/hepatic impairment
    Description

    Mildly agitated with renal/hepatic impairment

    Risperdal 2 mg PO and Ativan 2 mg PO every 8 hrs prn
    Description

    Risperdal 2 mg PO and Ativan 2 mg PO every 8 hrs prn

    Data type

    boolean

    Elderly/Frail
    Description

    Elderly/Frail

    Risperdal 0.5 mg PO and Ativan 0.5 mg PO every 8 hrs prn (not to exceed 3 in 24 hrs), OR
    Description

    Risperdal 0.5 mg PO and Ativan 0.5 mg PO every 8 hrs prn (not to exceed 3 in 24 hrs)

    Data type

    boolean

    Haldol 2 mg IM and Ativan 1 mg every 8 hrs prn; hold if BP < 100/60 mmHg
    Description

    Haldol 2 mg IM and Ativan 1 mg every 8 hrs prn; hold if BP < 100/60 mmHg

    Data type

    boolean

    IV
    Description

    IV

    IV
    Description

    IV

    Data type

    text

    If IV @mL/hr, please specify @mL/hr
    Description

    IV specification

    Data type

    integer

    Lab
    Description

    Lab

    Lab
    Description

    Lab

    Data type

    text

    If other labs, please specify
    Description

    Lab: specification of other labs

    Data type

    text

    Diagnostic Studies
    Description

    Diagnostic Studies

    Diagnostic Studies
    Description

    Diagnostic Studies

    Data type

    text

    Consult
    Description

    Consult

    Consult
    Description

    Consult

    Data type

    text

    Other Orders
    Description

    Other Orders

    Other Orders
    Description

    Other Orders

    Data type

    text

    Similar models

    AAFP: Acute Mental Status Change Admission Order

    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Name
    Item
    Name
    text
    Age
    Item
    Age of Patient
    integer
    C0001779 (UMLS CUI [1])
    Date of birth
    Item
    Date of birth
    date
    C0421451 (UMLS CUI [1])
    Medical Record Number
    Item
    Patient Hospital No.
    text
    C1301894 (UMLS CUI [1])
    Item Group
    Status
    Item
    Admission Status
    text
    Code List
    Admission Status
    CL Item
    Observation (1)
    CL Item
    Admission (2)
    CL Item
    Medical Floor (3)
    CL Item
    Monitored Bed (4)
    CL Item
    Other (5)
    Status: Other
    Item
    If Other, please specify:
    text
    Item Group
    Attending
    Attending physician
    Item
    Name of attending physician
    text
    C2361125 (UMLS CUI [1])
    Phone number
    Item
    Phone number of attending physician
    integer
    Item Group
    Admitting Diagnosis
    Acute Mental Status Change Associated Diagnosis
    Item
    Acute Mental Status Change Associated Diagnosis
    text
    Item Group
    Condition
    Item
    Condition
    text
    Code List
    Condition
    CL Item
    Stable (1)
    CL Item
    Fair (2)
    CL Item
    Serious (3)
    CL Item
    Critical (4)
    Item
    Code Status
    text
    Code List
    Code Status
    CL Item
    Full Code (1)
    CL Item
    DNR (2)
    Item Group
    Allergies
    Allergies
    Item
    Allergies
    text
    C0020517 (UMLS CUI [1])
    Item Group
    Diet
    Item
    Diet
    text
    Code List
    Diet
    CL Item
    NPO (1)
    CL Item
    Clear liquid (2)
    CL Item
    AHA step 2  (3)
    CL Item
    ADA in calories (4)
    CL Item
    Other (5)
    Diet: ADA specification
    Item
    If ADA, please specify amount of calories
    integer
    Diet: Other specification
    Item
    If other, please specify
    text
    Item Group
    Activity
    Item
    Activity
    text
    Code List
    Activity
    CL Item
    Bed rest with bedside commode (1)
    CL Item
    Bathroom privileges  (2)
    CL Item
    Up ad lib (3)
    CL Item
    Fall precautions (4)
    Item Group
    Nursing
    Nursing: Vital signs with neuro every 4 hrs for 24 hrs then every shift
    Item
    Vital signs with neuro every 4 hrs for 24 hrs then every shift
    boolean
    Nursing: Notify MD for: T > 101.5,Hr > 120, BP < 90/60 or > 180/110, decline in neurostatus, o2 sat < 92%
    Item
    Notify MD for: T > 101.5,Hr > 120, BP < 90/60 or > 180/110, decline in neurostatus, o2 sat < 92%
    boolean
    Nursing: Pulse ox every 8 hrs nasal cannula/face mask to maintain o2 sat > 92%
    Item
    Pulse ox every 8 hrs nasal cannula/face mask to maintain o2 sat > 92%
    boolean
    Nursing: I & O
    Item
    I & O
    boolean
    Item Group
    Medications (for aggressiv or psychotic behavior management) Composed of: 1) Acutely agitated and over 200 lbs without renal/hepatic impairment 2) Acutely/moderately agitated and under 20 lbs without renal/hepatic impairment 3) Mildly agitated with renal/hepatic impairment 4) Elderly/Frail
    Item Group
    Acutely agitated and over 200 lbs without renal/hepatic impairment
    Haldol 10 mg PO/IM, Ativan 4mg PO/IM and Cogentin 1 mg PO/IM every 6 hrs prn; hold if BP < 100/60 mmHg OR
    Item
    Haldol 10 mg PO/IM, Ativan 4mg PO/IM and Cogentin 1 mg PO/IM every 6 hrs prn; hold if BP < 100/60 mmHg OR
    boolean
    Geodon 20mg IM every 8 hrs prn; hold if BP < 100/60 mmHg
    Item
    Geodon 20mg IM every 8 hrs prn; hold if BP < 100/60 mmHg
    boolean
    Item Group
    Acutely/moderately agitated and under 200 lbs without renal/hepatic impairment
    Risperdal 2 mg and Ativan 2 mg PO ever 6 hrs prn
    Item
    Risperdal 2 mg and Ativan 2 mg PO ever 6 hrs prn, OR
    boolean
    Haldol 5 mg IM and Ativan 2 mg IM and Cogentin 1 mg IM every 4 hrs prn; hold if BP < 100/60 mmHg
    Item
    Haldol 5 mg IM and Ativan 2 mg IM and Cogentin 1 mg IM every 4 hrs prn; hold if BP < 100/60 mmHg, OR
    boolean
    Geodon 20 mg IM every 8 hrs prn; hold if BP < 100/60 mmHg
    Item
    Geodon 20 mg IM every 8 hrs prn; hold if BP < 100/60 mmHg, OR
    boolean
    Item Group
    Mildly agitated with renal/hepatic impairment
    Risperdal 2 mg PO and Ativan 2 mg PO every 8 hrs prn
    Item
    Risperdal 2 mg PO and Ativan 2 mg PO every 8 hrs prn
    boolean
    Item Group
    Elderly/Frail
    Risperdal 0.5 mg PO and Ativan 0.5 mg PO every 8 hrs prn (not to exceed 3 in 24 hrs)
    Item
    Risperdal 0.5 mg PO and Ativan 0.5 mg PO every 8 hrs prn (not to exceed 3 in 24 hrs), OR
    boolean
    Haldol 2 mg IM and Ativan 1 mg every 8 hrs prn; hold if BP < 100/60 mmHg
    Item
    Haldol 2 mg IM and Ativan 1 mg every 8 hrs prn; hold if BP < 100/60 mmHg
    boolean
    Item Group
    IV
    Item
    IV
    text
    Code List
    IV
    CL Item
    IV lock; flush per routine (1)
    CL Item
    IV @mL/hr (2)
    IV specification
    Item
    If IV @mL/hr, please specify @mL/hr
    integer
    Item Group
    Lab
    Item
    Lab
    text
    Code List
    Lab
    CL Item
    Admission: CBC, sed rate, comp met profile, serum ammonia, HIV, RPR, TSH, urine drug screen (1)
    CL Item
    Consider: serum for lead and heavy metals and lumbar puncture  (2)
    CL Item
    Other labs (3)
    Lab: specification of other labs
    Item
    If other labs, please specify
    text
    Item Group
    Diagnostic Studies
    Item
    Diagnostic Studies
    text
    Code List
    Diagnostic Studies
    CL Item
    CT head without contrast (1)
    CL Item
    CXR 2 view; reason: rule out bony abnormality/infiltrate (2)
    CL Item
    Consider carotid Doppler (3)
    Item Group
    Consult
    Consult
    Item
    Consult
    text
    Item Group
    Other Orders
    Other Orders
    Item
    Other Orders
    text

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