ID

16002

Beschreibung

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

Stichworte

Versionen (1)
  1. 26.06.16 26.06.16 -
Hochgeladen am

26. Juni 2016

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AAFP: Community Acquired Pneumonia Admission Order

Englisch

AAFP: Community Acquired Pneumonia Admission Order

1 Formulare  
Default Itemgroup
Beschreibung

Default Itemgroup

Name
Beschreibung

Name

Datentyp

text

Age
Beschreibung

Age

Datentyp

integer

Date of Birth
Beschreibung

Date of Birth

Datentyp

date

Medical Record
Beschreibung

Medical Record

Datentyp

integer

Status
Beschreibung

Status

Status
Beschreibung

Status

Datentyp

text

Attending
Beschreibung

Attending

Name of attending physician
Beschreibung

Name

Datentyp

text

Phone number of attending physician
Beschreibung

Phone

Datentyp

integer

Admitting Diagnosis
Beschreibung

Admitting Diagnosis

Pneumonia Associated Diagnoses
Beschreibung

Admitting Diagnosis

Datentyp

text

Condition
Beschreibung

Condition

Condition
Beschreibung

Condition

Datentyp

text

Allergies
Beschreibung

Allergies

Allergies
Beschreibung

Allergies

Datentyp

text

Diet
Beschreibung

Diet

Diet
Beschreibung

Diet

Datentyp

text

Activity
Beschreibung

Activity

Activity
Beschreibung

Activity

Datentyp

text

Nursing
Beschreibung

Nursing

Vital signs: every 4 hrs
Beschreibung

Nursing

Datentyp

boolean

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

Nursing

Datentyp

boolean

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

Nursing

Datentyp

boolean

Spot pulse ox on room air upon arrival
Beschreibung

Nursing

Datentyp

boolean

Respiratory distress or decreased LOC
Beschreibung

Nursing

Datentyp

boolean

IV
Beschreibung

IV

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

IV

Datentyp

boolean

IV lock; flush per routine
Beschreibung

IV

Datentyp

boolean

If KCL, please specify amount
Beschreibung

KCL specification

Datentyp

text

Maßeinheiten
  • mL/hr
mL/hr
Medications
Beschreibung

Medications

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

Question 2-4 have to be seen as one Item

Datentyp

boolean

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

Medications

Datentyp

boolean

Zithromycin or Levaquin
Beschreibung

Medications

Datentyp

text

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

Medications

Datentyp

boolean

MOM 30 mL PO every 12 hrs prn constipation
Beschreibung

Medications

Datentyp

boolean

Ambien 10 mg PO @ bedtime prn insomnia
Beschreibung

Medications

Datentyp

boolean

Other meds
Beschreibung

Medications

Datentyp

boolean

If O2 please specify via
Beschreibung

Specification of O2

Datentyp

text

If Other meds, please specify
Beschreibung

Specification of Other

Datentyp

text

Lab
Beschreibung

Lab

CBC, basal metabolic profile
Beschreibung

Lab

Datentyp

boolean

Blood cultures x2 STAT prior to antibiotics
Beschreibung

Lab

Datentyp

boolean

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

Lab

Datentyp

boolean

Chest X-ray
Beschreibung

Chest X-ray

Chest X-ray
Beschreibung

Chest X-ray

Datentyp

text

Patient Education
Beschreibung

Patient Education

Smoking cessation counseling
Beschreibung

Patient Education

Datentyp

boolean

Immunizations
Beschreibung

Immunizations

Immunizations: Influenza Vaccine (September-March)
Beschreibung

Immunizations

Datentyp

text

If Immunization not indicated, please specify reason
Beschreibung

Specification of not indicated

Datentyp

text

Immunizations: Pneumococcal vaccine (year around)
Beschreibung

Immunizations

Datentyp

text

If Immunization not indicated, please specify reason
Beschreibung

Specification of not indicated

Datentyp

text

Signature
Beschreibung

Signature

Datentyp

text

Name
Beschreibung

Name

Datentyp

text

Date and Time
Beschreibung

Date and Time

Datentyp

datetime

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Ähnliche Modelle

AAFP: Community Acquired Pneumonia Admission Order

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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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