AAFP: Community Acquired Pneumonia Admission Order

ID

16002

Description

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").

Lien

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

Mots-clés

D017714

EHR

D010343

Routine documentation

D011014

26/06/2016 26/06/2016 -

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26 juin 2016

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0

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1 Formulaires

StudyEvent: ODM
1. AAFP: Community Acquired Pneumonia Admission Order

Name

Type

Description | Question | Decode (Coded Value)

Type de données

Alias

Default Itemgroup

Item Group

Name

Item

Name

text

Age

Item

Age

integer

Date of Birth

Item

Date of Birth

date

Medical Record

Item

Medical Record

integer

Status

Item Group

Status

Item

Status

text

Status

Code List

Status

CL Item

Medical floor (1)

CL Item

ICU (2)

Attending

Item Group

Attending

Name

Item

Name of attending physician

text

Phone

Item

Phone number of attending physician

integer

Admitting Diagnosis

Item Group

Admitting Diagnosis

Item

Pneumonia Associated Diagnoses

text

Condition

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)

Allergies

Item Group

Allergies

Item

Allergies

text

Diet

Item Group

Diet

Item

Diet

text

Diet

Code List

Diet

CL Item

Regular as tolerated (1)

Activity

Item Group

Activity

Item

Activity

text

Activity

Code List

Activity

CL Item

Bed rest with bathroom privileges with assistance (1)

Nursing

Item Group

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

Item

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

boolean

Item

IV lock; flush per routine

boolean

KCL specification

Item

If KCL, please specify amount

text

Medications

Item Group

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

Medications

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

Specification of O2

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

Lab

Item Group

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

Chest X-ray

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)

Patient Education

Item Group

Patient Education

Item

Smoking cessation counseling

boolean

Immunizations

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

Immunizations

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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Mots-clés

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AAFP: Community Acquired Pneumonia Admission Order