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").

Lien

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

Mots-clés

  1. 13/06/2016 13/06/2016 -
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13 juin 2016

DOI

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Licence

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

Type de données

text

Age of Patient
Description

Age

Type de données

integer

Alias
UMLS CUI [1]
C0001779
Date of birth
Description

Date of birth

Type de données

date

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

Medical Record Number

Type de données

text

Alias
UMLS CUI [1]
C1301894
Status
Description

Status

Admission Status
Description

Status

Type de données

text

If Other, please specify:
Description

Status: Other

Type de données

text

Attending
Description

Attending

Name of attending physician
Description

Attending physician

Type de données

text

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

Phone number

Type de données

integer

Admitting Diagnosis
Description

Admitting Diagnosis

Acute Mental Status Change Associated Diagnosis
Description

Acute Mental Status Change Associated Diagnosis

Type de données

text

Condition
Description

Condition

Condition
Description

Condition

Type de données

text

Code Status
Description

Code Status

Type de données

text

Allergies
Description

Allergies

Allergies
Description

Allergies

Type de données

text

Alias
UMLS CUI [1]
C0020517
Diet
Description

Diet

Diet
Description

Diet

Type de données

text

If ADA, please specify amount of calories
Description

Diet: ADA specification

Type de données

integer

If other, please specify
Description

Diet: Other specification

Type de données

text

Activity
Description

Activity

Activity
Description

Activity

Type de données

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

Type de données

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%

Type de données

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%

Type de données

boolean

I & O
Description

Nursing: I & O

Type de données

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

Type de données

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

Type de données

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

Type de données

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

Type de données

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

Type de données

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

Type de données

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)

Type de données

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

Type de données

boolean

IV
Description

IV

IV
Description

IV

Type de données

text

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

IV specification

Type de données

integer

Lab
Description

Lab

Lab
Description

Lab

Type de données

text

If other labs, please specify
Description

Lab: specification of other labs

Type de données

text

Diagnostic Studies
Description

Diagnostic Studies

Diagnostic Studies
Description

Diagnostic Studies

Type de données

text

Consult
Description

Consult

Consult
Description

Consult

Type de données

text

Other Orders
Description

Other Orders

Other Orders
Description

Other Orders

Type de données

text

Similar models

AAFP: Acute Mental Status Change Admission Order

Name
Type
Description | Question | Decode (Coded Value)
Type de données
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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