ID

16008

Description

AAFP: CVA 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 tenth section ("CVA Admission Order").

Link

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

Keywords

Versions (1)
  1. 6/26/16 6/26/16 -
Uploaded on

June 26, 2016

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License

Creative Commons BY-NC 3.0
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AAFP: CVA Admission Order

English

AAFP: CVA Admission Order

1 forms  
Default Itemgroup
Description

Default Itemgroup

Name
Description

Name

Data type

text

Age
Description

Age

Data type

integer

Date of Birth
Description

Date of Birth

Data type

date

Medical record
Description

Medical record

Data type

integer

Status
Description

Status

Status
Description

Status

Data type

text

Attending
Description

Attending

Name of attending physician
Description

Name

Data type

text

Phone number of attending physician
Description

Phone number

Data type

integer

Admitting Diagnosis
Description

Admitting Diagnosis

CVA Associated Diagnoses
Description

Admitting Diagnosis

Data type

text

Condition
Description

Condition

Condition
Description

Condition

Data type

text

Code Status
Description

Code Status

Data type

text

Diet
Description

Diet

NPO
Description

Diet

Data type

boolean

Clear liquid
Description

Diet

Data type

boolean

AHA step 2
Description

Diet

Data type

boolean

ADA___calories
Description

Diet

Data type

boolean

If diet according to ADA, please specify amount of calories
Description

ADA specification

Data type

integer

Other
Description

Diet

Data type

boolean

If Other, please specify
Description

Specification of Other

Data type

text

Activity
Description

Activity

Activity
Description

Activity

Data type

text

Nursing
Description

Nursing

Vital signs with neuro checks every 4hrs for 24 hrs then per routine
Description

Nursing

Data type

boolean

Notify MD for: BP systolic < 90 or > 180 or > 105 diastolic; P < 60 or > 120; declining mental status or worsening of neurological symptoms
Description

Nursing

Data type

boolean

Weigth on arrival
Description

Nursing

Data type

boolean

I&O every shift
Description

Nursing

Data type

boolean

O2 @ 2,4,6 L/min via NC or FM
Description

Nursing

Data type

boolean

Check pulse ox on arrival and pen to maintain O2 sat > 92%
Description

Nursing

Data type

boolean

Medications
Description

Medications

ASA 81 mg PO daily
Description

Medications

Data type

boolean

Folate 1 mg PO daily
Description

Medications

Data type

boolean

IV
Description

IV

Dextrose 5% in 1/2 normal saline with 20 mEq KCl/L at 80 mL/hr
Description

IV

Data type

boolean

Hep lock
Description

IV

Data type

boolean

Other
Description

IV

Data type

boolean

If other, please specify
Description

Specification of Other

Data type

text

Lab
Description

Lab

Admission: CBC, PT/INR, comp med profile, cardiac profile
Description

Lab

Data type

boolean

a.m.: lipid profile, TSH
Description

Lab

Data type

boolean

Diagnostic Studies
Description

Diagnostic Studies

CT Head without contrast (if not done in ER)
Description

Diagnostic Studies

Data type

boolean

ECG (if not done in ER)
Description

Diagnostic Studies

Data type

boolean

Portable CXR (if not done in ER)
Description

Diagnostic Studies

Data type

boolean

Echocardiogram - to be read by__
Description

Diagnostic Studies

Data type

boolean

If Echocardiogram, please specify: to be read by___
Description

Echocardiogram specification

Data type

text

Diagnostic Studies
Description

Other

Data type

boolean

If Other, please specify
Description

Specification of Other

Data type

text

If Other, please specify
Description

Specification of Other

Data type

text

Consult
Description

Consult

PT evaluation
Description

Consult

Data type

boolean

OT evaluation
Description

Consult

Data type

boolean

Speech/swallow evaluation
Description

Consult

Data type

boolean

Signature
Description

Signature

Data type

text

Print Name
Description

Print Name

Data type

text

Date and Time
Description

Date and Time

Data type

datetime

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Similar models

AAFP: CVA Admission Order

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
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
Observation (1)
CL Item
Admission (2)
CL Item
Medical floor (3)
CL Item
Monitored bed (4)
CL Item
Other (5)
Item Group
Attending
Name
Item
Name of attending physician
text
Phone number
Item
Phone number of attending physician
integer
Item Group
Admitting Diagnosis
Admitting Diagnosis
Item
CVA 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
Code Status
text
Code Status
Code List
Code Status
CL Item
full status (1)
CL Item
DNR (2)
Item Group
Diet
Diet
Item
NPO
boolean
Diet
Item
Clear liquid
boolean
Diet
Item
AHA step 2
boolean
Diet
Item
ADA___calories
boolean
ADA specification
Item
If diet according to ADA, please specify amount of calories
integer
Diet
Item
Other
boolean
Specification of Other
Item
If Other, please specify
text
Item Group
Activity
Item
Activity
text
Activity
Code List
Activity
CL Item
Bed rest (1)
CL Item
Bed rest with bedside commode (2)
CL Item
Bathroom privileges with assistance (3)
Item Group
Nursing
Nursing
Item
Vital signs with neuro checks every 4hrs for 24 hrs then per routine
boolean
Nursing
Item
Notify MD for: BP systolic < 90 or > 180 or > 105 diastolic; P < 60 or > 120; declining mental status or worsening of neurological symptoms
boolean
Nursing
Item
Weigth on arrival
boolean
Nursing
Item
I&O every shift
boolean
Nursing
Item
O2 @ 2,4,6 L/min via NC or FM
boolean
Nursing
Item
Check pulse ox on arrival and pen to maintain O2 sat > 92%
boolean
Item Group
Medications
Medications
Item
ASA 81 mg PO daily
boolean
Medications
Item
Folate 1 mg PO daily
boolean
Item Group
IV
IV
Item
Dextrose 5% in 1/2 normal saline with 20 mEq KCl/L at 80 mL/hr
boolean
IV
Item
Hep lock
boolean
IV
Item
Other
boolean
Specification of Other
Item
If other, please specify
text
Item Group
Lab
Lab
Item
Admission: CBC, PT/INR, comp med profile, cardiac profile
boolean
Lab
Item
a.m.: lipid profile, TSH
boolean
Item Group
Diagnostic Studies
Diagnostic Studies
Item
CT Head without contrast (if not done in ER)
boolean
Diagnostic Studies
Item
ECG (if not done in ER)
boolean
Diagnostic Studies
Item
Portable CXR (if not done in ER)
boolean
Diagnostic Studies
Item
Echocardiogram - to be read by__
boolean
Echocardiogram specification
Item
If Echocardiogram, please specify: to be read by___
text
Diagnostic Studies
Item
boolean
Specification of Other
Item
If Other, please specify
text
Specification of Other
Item
If Other, please specify
text
Item Group
Consult
Consult
Item
PT evaluation
boolean
Consult
Item
OT evaluation
boolean
Consult
Item
Speech/swallow evaluation
boolean
Signature
Item
Signature
text
Print Name
Item
Print Name
text
Date and Time
Item
Date and Time
datetime
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