Lecture 4: Intro to Admission Orders Flashcards
What is the mnemonic for admssion orders?
ADC VANDALISM HERE
Two components of the Admition portion?
1) Where are you admitting the patient?
2) Who are you admitting the patient to?
What goes in the diagnosis portion of admission order?
- The most important diagnosis on top, the reason why they are being admitted
- Do NOT list differential diagnosis here!
* If patient came in after a fall and you aren’t quite sure why you would put: muscle weakness, UE tremor, unstable gait, lethargy
What is documented in the allergies portion of the admission order?
What is most important?
- MOST important is medication allergies; document the rxn to this med as well
- List intolerances
- Food allergies
A CBC with differential has what extra component?
Percentage and absolute differential counts (PMN, Lymph, Baso, Eos, Mono)
What are the extra values that come with a CMP vs. BMP?
- Albumin:Globulin (A:G) ration
- Albumin
- Alkaline phosphatase
- AST
- ALT
- Bilirubin, total
- Globulin, total
- Protein, total
What does the ‘I’ stand for in the admission order?
- Intravenous (IV)
- What should be given via IV
- What rate you want it running at
What goes in the “Special” component of the admission order?
- Special tests; Radiology/diagnostics: what body region you want imaged
- Consults (who and why): what specialists you need
What goes in the Medications portion of admission order?
- Reconcile home medications
- What new medications are needed?
What goes in the “House Officer” component of the admission order?
Notify house officer if a certain lab or some other being monitored goes outside of a range you are trying to keep it in
What are the correct order of steps in an abdominal PE vs. cardiovascular PE?
Abdominal: inspection, auscultation, percussion, palpation
Cardio: inspection, palpation, percussion, auscultation
