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