Admit Orders

ADULT
ADMIT TO SERVICE ORDERS 1 of 3

ALLERGIES Allergies
Patient ID Area bkPatientName bkAcctNum
DO NOT USE THESE UNSAFE ABBREVIATIONS: "u" and "fir should be unit, "Ug" should be mcg, "OD" should be daily, "QOD"
should be every other day, "BIW" should be two times a week, "TIW" should be three times a week, "AU," "AS,' "AD," "OS," and "OD" should be
written out in full. Correct Use of Leading and Trailing Zeros - Always Leading Never Trailing .1 should be 0.1 and 1.0 should be 1
Admit to Service:bkPhysician _____________________ Admit to (bed type):
Diagnosis: _____________________________________ Secondary Diagnosis:
DIAGNOSIS OF ANGINA, MYOCARDIAL INFARCTION (MI), STROKE, OR TRANSIENT ISCHEMIC ATTACK
(TIA) USE APPROPRIATE ORDER SET. DIAGNOSIS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
(COPD), PNEUMONIA, CONGESTIVE HEART FAILURE (CHF), PNEUMONIA AND CHF, OR DIVERTICULITIS
USChoose a building block.E APPROPRIATE ADDENDA TO THESE ORDERS.
Patient Condition: Choose an item. ____________________
Check,,circle and/or fill in all orders to be implemented as appropriate.
1.
ADVANCE DIRECTIVES: Full Support Do Not Resuscitate (DNR) Health Care Proxy
2.
VITAL SIGNS: Frequency: ____________ Special Requirements: ____________________________________
3.
DIET: _______________________________________________________________________________________
4.
5.
FLUID RESTRICTIONS: ________________________________________________________________________

ACTIVITY: N o Restrictions Out of Bed to Chair Bed Alarm - 0 t h e r : _________________________
6.
OXYGEN SUPPORT:
7.
IV FLUIDS: _____________________________________________________ or Intermittent Infusion Device
8.
INTAKE AND OUTPUT: Every________ hour(s)
9.
ADMISSION LAB WORK:
CULTURES: Urine
2 liter Nasal 0ther: ___________________________________________
Daily Weights
Basic Metabolic Panel (BMP)

Complete Metabolic Panel (CMP)
Complete Blood Count (CBC) with differential
Prothrornbin Time (PT)/Activated Partial Thromboplastin Time (aPTT)
Type and Screen
Urinalysis
Urinalysis with microscope
Sputum
Blood (2)
0ther: _______________________________
Other Labs: ___________________________________________________________________________________

c
10. DIAGNOSTICS:
Chest X-ray (indication): ____________________________________________________

0ther Study (indication): _____________________________________________________
Electrocardiogram (ECG)
11. CONSULTATIONS: _________________________________ indication: ______________________________
indication:
12. REFERRALS (indication):

Physical Therapy _____________________________ Rehabilitation Medicine Consult ________________
Patient Management ___________________________ Social Services ______________________________
Nutritional Services ___________________________ Speech & Swallow Evaluation ___________________
No Pastoral Care _______________________________ No Palliative Care ______________________________
13. LEVEL OF OBSERVATION (Psychiatric Patients): __________________________________________________
Date:12/10/11Time:9:45 PM
Physician/NP/PA SignaturePlace STAT barcode sticker

within this box only on form
copy being scanned
it
if
Buffalo General Hospital

DeGraff Memorial Hospital
Millard Fillmore Gates Circle Hospital
Millard Fillmore Suburban Hospital
Women & Children's, Hospital of Buffalo
Others:
ADULT
ADMIT TO SERVICE ORDERS 2 of 3
Patient ID AreabkPatientName
DO NOT USE THESE UNSAFE ABBREVIATIONS: "U" and "IU" should be unit, "Ug" should be mcg, "OD" should be daily, "DOD"
should be every other day, "BIW" should be two times a week, "TIW" should be three times a week, "AU," AS," AD," "OS," and "OD" should be
written out in full. Correct Use of Leading and Trailing Zeros - Always Leading Never Trailing .1 should be 0.1 and 1.0 should be 1
() Check, circle and/or fill in all orders to be implemented as appropriate.

14. MEDICATIONS:
A. DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS (Risk Assessment on Back)
REQUIRED to () check all that apply:
Heparin 5000 units subcutaneous every 8 hours
Enoxaparin 40 mg subcutaneous'daily
Enoxaparin 30 mg (if Glomerular Filtration Rate is less than 30) subcutaneous daily
Pneumatic Compression Device (PCD): Knee High Pump

1:1Pneumatic Compression Device (PCD): Foot Pump
Deep Vein Thrombosis Other Orders: Prophylaxis not indicated (Reason): ______________________________________________________________
DVT Prophylaxis contraindicated (Reason): _____________________________________________________
B. EXISTING MEDICATIONS: COMPLETE MEDICATION RECONCILIATION FORM KH01116
C. NEW MEDICATIONS
Analgesic (Pain) Medication
dose
route
interval
________________________________________ a
r)
(p
d
e
sn
Fever Management Medication
dose
route
interval
________________________________________ a
)
m
(p
d
e
sn
Other Medication
dose
route
interval
indication
a ______________________________
b. _______________________
C._____________________________________
d. _______________________________
e. _____________________________________
D. IMMUNIZATIONS
OPer New York State Department of Health Mandatory (NYS DOH) Immunization Program and Kaleida Policy CL.6,
administer vaccine(s) if patient meets criteria.
Pneumococcal Vaccine 0.5 ml intramuscular x 1 for prophylaxis
If contraindicated please () check one of the NYS DOH acceptable contraindications below:
Allergy to pneumococcal vaccine
Previously immunized
Date: _______________
Influenza Vaccine 0.5 ml intramuscular x 1 for prophylaxis (September .1 - April 1) If

contraindicated please () check one of the NYS DOH acceptable contraindications below:
Allergy to influenza
vaccine
Vaccinated this flu season
Date: _______________
15. ADDITIONAL ORDERS: ___________________________________________________________________________
Date:12/10/11
Time:9:45 PM_____ Physician/NP/PA Signature. ______________________________________

Place STAT barcode sticker
within this box only on form
copy being scanned

Admit Orders

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ADULT

ADMIT TO SERVICE ORDERS 1 of 3

Patient ID Area bkPatientName bkAcctNum

VITAL SIGNS: Frequency: ____________ Special Requirements: ____________________________________

FLUID RESTRICTIONS: ________________________________________________________________________

IV FLUIDS: _____________________________________________________ or Intermittent Infusion Device

INTAKE AND OUTPUT: Every________ hour(s)

ADMISSION LAB WORK:

2 liter Nasal 0ther: ___________________________________________

Basic Metabolic Panel (BMP)

Other Labs: ___________________________________________________________________________________

Chest X-ray (indication): ____________________________________________________

11. CONSULTATIONS: _________________________________ indication: ______________________________

12. REFERRALS (indication):

Physician/NP/PA SignaturePlace STAT barcode sticker

Buffalo General Hospital

() Check, circle and/or fill in all orders to be implemented as appropriate.

Pneumatic Compression Device (PCD): Knee High Pump

Fever Management Medication

Influenza Vaccine 0.5 ml intramuscular x 1 for prophylaxis (September .1 - April 1) If

Vaccinated this flu season

15. ADDITIONAL ORDERS: ___________________________________________________________________________

Time:9:45 PM_____ Physician/NP/PA Signature. ______________________________________

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VITAL SIGNS: Frequency: Special Requirements: ________________________

11. CONSULTATIONS: ___ indication:

Time:9:45 PM_ Physician/NP/PA Signature. __________________________________