Admission Order, Preo, Post Op

Question 1

What is an “order”

Answer 1

Plan of care or any change in action
*A new order must be written for any alteration

Question 2

When are verbal orders okay?

Answer 2

In emergent or urgent situations

Question 3

What is the acronym for initial admission orders?

Answer 3

AD+ CAVA+
DIMPLS+O

Question 4

What does AD+ CAVA+ stand for?

Answer 4

A: admit/transfer
D: diagnosis
C: condition
A: activity
V: vital signs
A: allergies

Question 5

What does DIMPLS+ O stand for?

Answer 5

D: diet
IV/I: Interventions
M: medications
P: procedures
L: labs
S: special instructions
O: other

Question 6

What should go under admit?

Answer 6

1. Attending HCP name
2. Unit/Floor
3. If PCP is not the same as the attending, part of orders should be notified to them

Question 7

What should go under Diagnosis

Answer 7

1. Diagnosis that caused the patient to be admitted (primary)
2. Any other diagnosis that the patient currently has (comorbidities- secondary)

Question 8

What goes under condition?

Answer 8

1. General condition of patient at the time of admission
2. Code status
   EX: stable, full code

Question 9

What goes under the activity?

Answer 9

1. Restrictions on the patients activity
   *bed rest
   *Bathroom privileges
   *Ambulation

Question 10

What goes under vital signs?

Answer 10

1. Which vital sign+frequency (how often they are checked)
2. Parameters of vitals
   *Notify is under or above a certain amount

Question 11

What goes under allergies?

Answer 11

1. Medication, food, environmental
2. State reaction if known

Question 12

What goes under diet?

Answer 12

1. state any dietary restrictions

Question 13

What goes under IVs/ Interventions

Answer 13

1. Ordering IV fluids
   *type of fluid
   *any additives
   *rate

Question 14

What does heplock mean?

Answer 14

IV but no fluid flowing

Question 15

What does KVO mean?

Answer 15

Keep vein open

Question 16

What goes under medication?

Answer 16

1. Medications specific to patients primary diagnosis
2. Other meds that pateint is currently taking
3. PRN meds
4. Include dose, mode of administration and frequency

Question 17

What goes under procedures?

Answer 17

1. Surgical
2. Intervention
3. What needs to be completed prior

Question 18

What goes under Labs, X-rays, Diagnostics?

Answer 18

1. Labs that need to be drawn and when they should take place
2. Imaging modalities
   *include why

Question 19

What gos under special instructions?

Answer 19

1. O2 monitoring
2. Accu-checks
3. Wound care
4. Drain care and amount documentation

Question 20

What goes under other?

Answer 20

1. Consults
2. Courtesy notifications
3. Discharge planning

Question 21

When are pre-operative notes written?

Answer 21

Written in the progress notes prior to surgery

Question 22

Who completes the operative note?

Answer 22

The performing physician
*written in the progress notes on the day of the surgery

Question 23

What is a daily progress note?

Answer 23

Shows the response to treatment an determine progress or any new problems, goal is discharge

Question 24

What format does a daily progress note follow?

Answer 24

SOAP

Question 25

What is patient elopement?

Answer 25

1. Patient leaves the hospital without being discharged
2. Does not notify nursing or medical staff
3. “Patient eloped”

Question 26

What is Against Medical Advice (AMA)

Answer 26

1. Patient has a desire to leave the hospital before being ready for discharge
2. Notify the admitting am
3. Must discuss with the patient the benefits of continued hospitalizations and treatment and risk
4. Document conversation