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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