Writing physician orders by hand (EHR does not work)

If writing out Physician Orders by hand:

Assign to __________ status (observation/inpatient)

Attending:

Diagnosis: (may be symptoms if Dx is unknown)

Vitals: Check q6hrs

Allergies: (note reaction to each)

Nursing: (special instructions, ex: “oxygen per NC 2L”)

Diet: clear liquids and advance as tolerated, NPO, heart healthy

Is/Os: q shift

Medications: (list out home meds that you wish to continue in the hospital)

New medications (additional ones that you are adding while in the hospital): include IV fluids (ex: NS @ 150cc/hr X 2 L)

Labs: (to be drawn/performed, ex: “Troponin I q6hrs X2, BMP qd X 2 days, CBC qd X 2 days”)

Special studies: (ex: “EKG stat and q6hrs X2”)

DVT prophylaxis:

  • Lovenox:
    1. Prophylactic: Lovenox 40mg SubQ qd
    2. Therapeutic: Lovenox 1mg/kg/dose SubQ q12hrs
  • Heparin 5,000 U subQ q12 hrs
    1. Renal failure
  • SCD

 

 

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