Orders for a Hospital Admission

Summary

  • Admit to (ask if you don’t know)
  • Allergies and adverse reactions (really important)
    • may have to write in a few places
    • write what the rxn is
  • Diagnosis
    • sometimes vague: chest pain, NOS
  • Diet
    • specific list at KGH (comes frozen from Ottawa)
    • different in each hospital
    • includes NPO: nil by mouth (particularly if potential┬ásx)
  • Activity
    • often “as tolerated”
    • depends on clinical scenario
    • CCU specific: “”
  • Vitals:
    • which ones and how often
    • try to avoid “routine” if you don’t know what it means
  • Investigations:
    • bloodwork, radiology most common
    • others
  • Drugs
    • all medications that patient will be on in hospital will be written on the order

Other Considerations

  • Others:
    • consults
    • code status
    • special considerations (bed, unit)
  • Pre-printed orders
    • differ with each service
    • read them carefully

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