ID

15769

Descripción

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

Palabras clave

  1. 13/6/16 13/6/16 -
Subido en

13 de junio de 2016

DOI

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Licencia

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
Descripción

Default Itemgroup

Name
Descripción

Name

Tipo de datos

text

Age of Patient
Descripción

Age

Tipo de datos

integer

Alias
UMLS CUI [1]
C0001779
Date of birth
Descripción

Date of birth

Tipo de datos

date

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

Medical Record Number

Tipo de datos

text

Alias
UMLS CUI [1]
C1301894
Status
Descripción

Status

Admission Status
Descripción

Status

Tipo de datos

text

If Other, please specify:
Descripción

Status: Other

Tipo de datos

text

Attending
Descripción

Attending

Name of attending physician
Descripción

Attending physician

Tipo de datos

text

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

Phone number

Tipo de datos

integer

Admitting Diagnosis
Descripción

Admitting Diagnosis

Acute Mental Status Change Associated Diagnosis
Descripción

Acute Mental Status Change Associated Diagnosis

Tipo de datos

text

Condition
Descripción

Condition

Condition
Descripción

Condition

Tipo de datos

text

Code Status
Descripción

Code Status

Tipo de datos

text

Allergies
Descripción

Allergies

Allergies
Descripción

Allergies

Tipo de datos

text

Alias
UMLS CUI [1]
C0020517
Diet
Descripción

Diet

Diet
Descripción

Diet

Tipo de datos

text

If ADA, please specify amount of calories
Descripción

Diet: ADA specification

Tipo de datos

integer

If other, please specify
Descripción

Diet: Other specification

Tipo de datos

text

Activity
Descripción

Activity

Activity
Descripción

Activity

Tipo de datos

text

Nursing
Descripción

Nursing

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

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

Tipo de datos

boolean

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

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

Tipo de datos

boolean

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

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

Tipo de datos

boolean

I & O
Descripción

Nursing: I & O

Tipo de datos

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
Descripción

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
Descripción

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
Descripción

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

Tipo de datos

boolean

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

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

Tipo de datos

boolean

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

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

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

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

Tipo de datos

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
Descripción

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

Tipo de datos

boolean

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

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

Tipo de datos

boolean

Mildly agitated with renal/hepatic impairment
Descripción

Mildly agitated with renal/hepatic impairment

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

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

Tipo de datos

boolean

Elderly/Frail
Descripción

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
Descripción

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

Tipo de datos

boolean

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

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

Tipo de datos

boolean

IV
Descripción

IV

IV
Descripción

IV

Tipo de datos

text

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

IV specification

Tipo de datos

integer

Lab
Descripción

Lab

Lab
Descripción

Lab

Tipo de datos

text

If other labs, please specify
Descripción

Lab: specification of other labs

Tipo de datos

text

Diagnostic Studies
Descripción

Diagnostic Studies

Diagnostic Studies
Descripción

Diagnostic Studies

Tipo de datos

text

Consult
Descripción

Consult

Consult
Descripción

Consult

Tipo de datos

text

Other Orders
Descripción

Other Orders

Other Orders
Descripción

Other Orders

Tipo de datos

text

Similar models

AAFP: Acute Mental Status Change Admission Order

Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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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