1. Admit patient to ________ (SPECIALTY) under Dr. _________ (ATTENDING STAFF).
2. Diagnosis: ________. If a diagnosis is uncertain, write the issue plus “NYD” (not yet diagnosed).
3. DNR/MOST Status: M1, M2, M3, C0, C1,C2; if unknown, do not write anything.
4. Diet: DAT = diet as tolerated, Renal Diet (low K and low Na), Heart Healthy (low sodium, low fat), Diabetic diet, NPO = nothing by mouth.
5. Activity: AAT = activity as tolerated; bed rest; fall risk
6. Vitals: q4h, q8h, qAM, qShift
7. Instructions to nurse: This may include daily weights, capillary blood sugar monitoring, monitoring urine output, etc.
8. I.V. Orders:
IV saline lock (ensures patient has IV in place, but nothing running through it)
IV TKVO (to keep vein open) = very low rate to keep IV patent (10-20 ml/hour)
IV rate with IV fluid type
9. Investigations: blood work, radiology, EKGs, consultations, etc...
10. Isolation status: airborne, contact, droplet, write nothing if none
11. Drugs (6 P`s):
Poop (laxatives or stool softeners)
Complete Best Possible Medication History (BPMH) with patient for home medications.