ID

16008

Beschrijving

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

Trefwoorden

  1. 26-06-16 26-06-16 -
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26 juni 2016

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Creative Commons BY-NC 3.0

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AAFP: CVA Admission Order

AAFP: CVA Admission Order

Default Itemgroup
Beschrijving

Default Itemgroup

Name
Beschrijving

Name

Datatype

text

Age
Beschrijving

Age

Datatype

integer

Date of Birth
Beschrijving

Date of Birth

Datatype

date

Medical record
Beschrijving

Medical record

Datatype

integer

Status
Beschrijving

Status

Status
Beschrijving

Status

Datatype

text

Attending
Beschrijving

Attending

Name of attending physician
Beschrijving

Name

Datatype

text

Phone number of attending physician
Beschrijving

Phone number

Datatype

integer

Admitting Diagnosis
Beschrijving

Admitting Diagnosis

CVA Associated Diagnoses
Beschrijving

Admitting Diagnosis

Datatype

text

Condition
Beschrijving

Condition

Condition
Beschrijving

Condition

Datatype

text

Code Status
Beschrijving

Code Status

Datatype

text

Diet
Beschrijving

Diet

NPO
Beschrijving

Diet

Datatype

boolean

Clear liquid
Beschrijving

Diet

Datatype

boolean

AHA step 2
Beschrijving

Diet

Datatype

boolean

ADA___calories
Beschrijving

Diet

Datatype

boolean

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

ADA specification

Datatype

integer

Other
Beschrijving

Diet

Datatype

boolean

If Other, please specify
Beschrijving

Specification of Other

Datatype

text

Activity
Beschrijving

Activity

Activity
Beschrijving

Activity

Datatype

text

Nursing
Beschrijving

Nursing

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

Nursing

Datatype

boolean

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

Nursing

Datatype

boolean

Weigth on arrival
Beschrijving

Nursing

Datatype

boolean

I&O every shift
Beschrijving

Nursing

Datatype

boolean

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

Nursing

Datatype

boolean

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

Nursing

Datatype

boolean

Medications
Beschrijving

Medications

ASA 81 mg PO daily
Beschrijving

Medications

Datatype

boolean

Folate 1 mg PO daily
Beschrijving

Medications

Datatype

boolean

IV
Beschrijving

IV

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

IV

Datatype

boolean

Hep lock
Beschrijving

IV

Datatype

boolean

Other
Beschrijving

IV

Datatype

boolean

If other, please specify
Beschrijving

Specification of Other

Datatype

text

Lab
Beschrijving

Lab

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

Lab

Datatype

boolean

a.m.: lipid profile, TSH
Beschrijving

Lab

Datatype

boolean

Diagnostic Studies
Beschrijving

Diagnostic Studies

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

Diagnostic Studies

Datatype

boolean

ECG (if not done in ER)
Beschrijving

Diagnostic Studies

Datatype

boolean

Portable CXR (if not done in ER)
Beschrijving

Diagnostic Studies

Datatype

boolean

Echocardiogram - to be read by__
Beschrijving

Diagnostic Studies

Datatype

boolean

If Echocardiogram, please specify: to be read by___
Beschrijving

Echocardiogram specification

Datatype

text

Diagnostic Studies
Beschrijving

Other

Datatype

boolean

If Other, please specify
Beschrijving

Specification of Other

Datatype

text

If Other, please specify
Beschrijving

Specification of Other

Datatype

text

Consult
Beschrijving

Consult

PT evaluation
Beschrijving

Consult

Datatype

boolean

OT evaluation
Beschrijving

Consult

Datatype

boolean

Speech/swallow evaluation
Beschrijving

Consult

Datatype

boolean

Signature
Beschrijving

Signature

Datatype

text

Print Name
Beschrijving

Print Name

Datatype

text

Date and Time
Beschrijving

Date and Time

Datatype

datetime

Similar models

AAFP: CVA Admission Order

Name
Type
Description | Question | Decode (Coded Value)
Datatype
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
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
Code List
Condition
CL Item
Stable (1)
CL Item
Fair (2)
CL Item
Serious (3)
CL Item
Critical (4)
Item
Code Status
text
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
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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