Information:
Fel:
ID
15769
Beskrivning
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").
Länk
http://www.aafp.org/fpm/2006/0900/p49.html
Nyckelord
Versioner (1)
- 2016-06-13 2016-06-13 -
Uppladdad den
13 juni 2016
DOI
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Licens
Creative Commons BY-NC 3.0
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AAFP: Acute Mental Status Change Admission Order
AAFP: Acute Mental Status Change Admission Order
- StudyEvent: ODM
Similar models
AAFP: Acute Mental Status Change Admission Order
- StudyEvent: ODM
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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])
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
Attending physician
Item
Name of attending physician
text
C2361125 (UMLS CUI [1])
Phone number
Item
Phone number of attending physician
integer
Acute Mental Status Change Associated Diagnosis
Item
Acute Mental Status Change Associated Diagnosis
text
CL Item
Stable (1)
CL Item
Fair (2)
CL Item
Serious (3)
CL Item
Critical (4)
CL Item
Full Code (1)
CL Item
DNR (2)
Allergies
Item
Allergies
text
C0020517 (UMLS CUI [1])
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
CL Item
Bed rest with bedside commode (1)
CL Item
Bathroom privileges (2)
CL Item
Up ad lib (3)
CL Item
Fall precautions (4)
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
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
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
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
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)
Consult
Item
Consult
text
Other Orders
Item
Other Orders
text