ID

16002

Descripción

AAFP: Community Acquired Pneumonia Admission Order, Standardized 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 eighth section ("Community Acquired Pneumonia Admission Order").

Link

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

Palabras clave

Versiones (1)
  1. 26/6/16 26/6/16 -
Subido en

26 de junio de 2016

DOI

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Licencia

Creative Commons BY-NC 3.0
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AAFP: Community Acquired Pneumonia Admission Order

Inglés

AAFP: Community Acquired Pneumonia Admission Order

1 formularios  
Default Itemgroup
Descripción

Default Itemgroup

Name
Descripción

Name

Tipo de datos

text

Age
Descripción

Age

Tipo de datos

integer

Date of Birth
Descripción

Date of Birth

Tipo de datos

date

Medical Record
Descripción

Medical Record

Tipo de datos

integer

Status
Descripción

Status

Status
Descripción

Status

Tipo de datos

text

Attending
Descripción

Attending

Name of attending physician
Descripción

Name

Tipo de datos

text

Phone number of attending physician
Descripción

Phone

Tipo de datos

integer

Admitting Diagnosis
Descripción

Admitting Diagnosis

Pneumonia Associated Diagnoses
Descripción

Admitting Diagnosis

Tipo de datos

text

Condition
Descripción

Condition

Condition
Descripción

Condition

Tipo de datos

text

Allergies
Descripción

Allergies

Allergies
Descripción

Allergies

Tipo de datos

text

Diet
Descripción

Diet

Diet
Descripción

Diet

Tipo de datos

text

Activity
Descripción

Activity

Activity
Descripción

Activity

Tipo de datos

text

Nursing
Descripción

Nursing

Vital signs: every 4 hrs
Descripción

Nursing

Tipo de datos

boolean

ABG if Pulse ox < 90% or severe respiratory distress
Descripción

Nursing

Tipo de datos

boolean

Notify MD for BP < 90/60 or > 180/120; HR < 60 or > 120; T > 102.5; RR < 12 or > 28
Descripción

Nursing

Tipo de datos

boolean

Spot pulse ox on room air upon arrival
Descripción

Nursing

Tipo de datos

boolean

Respiratory distress or decreased LOC
Descripción

Nursing

Tipo de datos

boolean

IV
Descripción

IV

Dextrose 5% in 1/2 normal saline with 20 mEq KCL @___mL/hr
Descripción

IV

Tipo de datos

boolean

IV lock; flush per routine
Descripción

IV

Tipo de datos

boolean

If KCL, please specify amount
Descripción

KCL specification

Tipo de datos

text

Unidades de medida
  • mL/hr
mL/hr
Medications
Descripción

Medications

O2 @ 2,4,6 L/min via: NC, OR or FM
Descripción

Question 2-4 have to be seen as one Item

Tipo de datos

boolean

Ceftriaxone (Rocephin) 1 GM IVPB STAT after culture, PLUS (next Item)
Descripción

Medications

Tipo de datos

boolean

Zithromycin or Levaquin
Descripción

Medications

Tipo de datos

text

Tylenol 650 mg PO every 4-6 hrs prn pain/fever
Descripción

Medications

Tipo de datos

boolean

MOM 30 mL PO every 12 hrs prn constipation
Descripción

Medications

Tipo de datos

boolean

Ambien 10 mg PO @ bedtime prn insomnia
Descripción

Medications

Tipo de datos

boolean

Other meds
Descripción

Medications

Tipo de datos

boolean

If O2 please specify via
Descripción

Specification of O2

Tipo de datos

text

If Other meds, please specify
Descripción

Specification of Other

Tipo de datos

text

Lab
Descripción

Lab

CBC, basal metabolic profile
Descripción

Lab

Tipo de datos

boolean

Blood cultures x2 STAT prior to antibiotics
Descripción

Lab

Tipo de datos

boolean

Sputum for gram stain, C&S and consider AFB
Descripción

Lab

Tipo de datos

boolean

Chest X-ray
Descripción

Chest X-ray

Chest X-ray
Descripción

Chest X-ray

Tipo de datos

text

Patient Education
Descripción

Patient Education

Smoking cessation counseling
Descripción

Patient Education

Tipo de datos

boolean

Immunizations
Descripción

Immunizations

Immunizations: Influenza Vaccine (September-March)
Descripción

Immunizations

Tipo de datos

text

If Immunization not indicated, please specify reason
Descripción

Specification of not indicated

Tipo de datos

text

Immunizations: Pneumococcal vaccine (year around)
Descripción

Immunizations

Tipo de datos

text

If Immunization not indicated, please specify reason
Descripción

Specification of not indicated

Tipo de datos

text

Signature
Descripción

Signature

Tipo de datos

text

Name
Descripción

Name

Tipo de datos

text

Date and Time
Descripción

Date and Time

Tipo de datos

datetime

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Similar models

AAFP: Community Acquired Pneumonia Admission Order

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Name
Item
Name
text
Age
Item
Age
integer
Date of Birth
Item
Date of Birth
date
Medical Record
Item
Medical Record
integer
Item Group
Status
Item
Status
text
Status
Code List
Status
CL Item
Medical floor (1)
CL Item
ICU (2)
Item Group
Attending
Name
Item
Name of attending physician
text
Phone
Item
Phone number of attending physician
integer
Item Group
Admitting Diagnosis
Admitting Diagnosis
Item
Pneumonia Associated Diagnoses
text
Item Group
Condition
Item
Condition
text
Condition
Code List
Condition
CL Item
Stable (1)
CL Item
Fair (2)
CL Item
Serious (3)
CL Item
Critical (4)
Item Group
Allergies
Allergies
Item
Allergies
text
Item Group
Diet
Item
Diet
text
Diet
Code List
Diet
CL Item
Regular as tolerated (1)
Item Group
Activity
Item
Activity
text
Activity
Code List
Activity
CL Item
Bed rest with bathroom privileges with assistance (1)
Item Group
Nursing
Nursing
Item
Vital signs: every 4 hrs
boolean
Nursing
Item
ABG if Pulse ox < 90% or severe respiratory distress
boolean
Nursing
Item
Notify MD for BP < 90/60 or > 180/120; HR < 60 or > 120; T > 102.5; RR < 12 or > 28
boolean
Nursing
Item
Spot pulse ox on room air upon arrival
boolean
Nursing
Item
Respiratory distress or decreased LOC
boolean
Item Group
IV
IV
Item
Dextrose 5% in 1/2 normal saline with 20 mEq KCL @___mL/hr
boolean
IV
Item
IV lock; flush per routine
boolean
KCL specification
Item
If KCL, please specify amount
text
Item Group
Medications
Medications
Item
O2 @ 2,4,6 L/min via: NC, OR or FM
boolean
Medications
Item
Ceftriaxone (Rocephin) 1 GM IVPB STAT after culture, PLUS (next Item)
boolean
Item
Zithromycin or Levaquin
text
Medications
Code List
Zithromycin or Levaquin
CL Item
Zithromycin 500mg IV or PO daily OR (1)
CL Item
Levaquin 500 mg IV or PO daily (2)
Medications
Item
Tylenol 650 mg PO every 4-6 hrs prn pain/fever
boolean
Medications
Item
MOM 30 mL PO every 12 hrs prn constipation
boolean
Medications
Item
Ambien 10 mg PO @ bedtime prn insomnia
boolean
Medications
Item
Other meds
boolean
Item
If O2 please specify via
text
Specification of O2
Code List
If O2 please specify via
CL Item
NC (1)
CL Item
OR (2)
CL Item
FM (3)
Specification of Other
Item
If Other meds, please specify
text
Item Group
Lab
Lab
Item
CBC, basal metabolic profile
boolean
Lab
Item
Blood cultures x2 STAT prior to antibiotics
boolean
Lab
Item
Sputum for gram stain, C&S and consider AFB
boolean
Item Group
Chest X-ray
Item
Chest X-ray
text
Chest X-ray
Code List
Chest X-ray
CL Item
PA & Lat if not done previously (1)
Item Group
Patient Education
Patient Education
Item
Smoking cessation counseling
boolean
Item Group
Immunizations
Item
Immunizations: Influenza Vaccine (September-March)
text
Immunizations
Code List
Immunizations: Influenza Vaccine (September-March)
CL Item
Administer influenza vaccine 0.5 mL on day of discharge (1)
CL Item
Patient has been immunized this flu season (2)
CL Item
Immunization not indicated due to__ (3)
Specification of not indicated
Item
If Immunization not indicated, please specify reason
text
Item
Immunizations: Pneumococcal vaccine (year around)
text
Immunizations
Code List
Immunizations: Pneumococcal vaccine (year around)
CL Item
Administer pneumococcal vaccine 0.5 mL on day of discharge (1)
CL Item
Patient previously immunized after age 65 years (2)
CL Item
Patient previously immunized before age 65, but < 5 years ago (3)
CL Item
Immunization not indicated due to___ (4)
Specification of not indicated
Item
If Immunization not indicated, please specify reason
text
Signature
Item
Signature
text
Name
Item
Name
text
Date and Time
Item
Date and Time
datetime
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