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Clinician's Pocket Reference > Chapter 2. Chartwork >
How to Write Orders Many hospital systems are using online order entry. It is good practice to review the orders in a manual sequence before the order entry is completed by an authorized physician. The following format is useful for writing concise admission, transfer, and postoperative orders. It involves the mnemonic A.A.D.C. VAAN DISSL, which stands for Admit/Attending, Diagnosis, Condition, Vitals, Activity, Allergies, Nursing procedures, Diet, Ins and outs, Specific medications, Symptomatic medications, and Labs. |
A.D.C. VAAN DISSL - Admit: Admitting team, room number
- Attending: Name of the attending physician (the person legally responsible for the patient's care) as well as the resident's and intern's names
- Diagnosis: List admitting diagnosis or procedure if postop orders.
- Condition: Stable, critical, etc
- Vitals: Determine frequency of vital signs (temperature, pulse, BP, CVP, PCWP, weight, etc)
- Activity: Bedrest, up ad lib, ambulate qid, bathroom privileges, etc
- Allergies: Drug reactions and food or environmental allergies (eg, latex, adhesive tape)
- Nursing Procedures
- Bed Position. Elevate head of bed 30 degrees, etc
- Preps. Enemas, scrubs, showers
- Respiratory Care. P&PD, TC&DB, etc
- Dressing Changes, Wound Care. Change dressing bid, etc
- Notify House Officer If. Temperature > 101 F, BP < 90 mm Hg, etc
- Diet: NPO, clear liquid, regular, etc
- Ins and Outs: All "tubes" a patient may have
- Record Daily I&O.
- IV Fluids. Specify type and rate.
- Drains.
- NG Tube, Foley Catheter, ETT, Arterial Lines, Pulmonary Artery Catheter. Specify care desired (eg, NG to low wall suction, Foley to gravity, suction ETT q2h and PRN)
- Specific Medications: Diuretic, antibiotics, hormones, etc
- Symptomatic Medications: PRN medications (eg, pain medications, laxatives, sleep medications)
- Labs: Studies such as blood and urine. Times if applicable. Also includes ECGs, radiographs, nuclear scans, consultation requests, etc
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SOAP Note or Daily Progress Note SOAP stands for Subjective, Objective, Assessment, and Plan. A sample ICU progress note is reviewed in Chapter 20. S or subjective is how patients say they are feeling that morning. Record their subjective answers to history-related questions. For example, for a patient admitted with chest pain, record the answers to daily follow-up questions: Any further chest pain? If so, how long did it last? Any shortness of breath? How did you sleep last night? O or objective is the place for recording the physical examination and laboratory data. The physical examination should include at least general appearance, vital signs, chest, heart, and abdomen, and any other system in which there is a new complaint or in which there was a finding on admission. Laboratory data may include tests such as the left and right heart catheterization performed the afternoon before or the troponin and CBC drawn the morning the SOAP note is being written. A is the place for recording the Assessment of the patient. Evaluate the data, and record any conclusions drawn. P is where the Plan for the day is recorded. Include any new lab tests or medications, changes or additions to previous orders, and discharge or transfer plans. If the patient has more than one medical problem, address the Assessment and Plan for each problem separately. - 1. List each medical, surgical, and psychiatric problem separately: pneumonia, pancreatitis, CHF, etc.
- 2. Give each problem a call number: 1, 2, 3 (as in the Problem List).
- 3. Retain the number of each problem throughout the hospitalization.
- 4. When the problem is solved, mark it as such and delete it from the daily progress note.
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Discharge Summary/Note At most hospitals a formal discharge note usually is required for any admission longer than 24 h. This note is a framework for the complete dictated note and is a reference, if needed, before the dictated note is transcribed and filed. The following skeleton includes most of the information needed for a discharge note. - Date of Admission: Specify.
- Date of Discharge: Specify.
- Admitting Diagnosis: List main reason for initial admission.
- Discharge Diagnosis: List primary diagnosis and any secondary diagnoses.
- Attending Physician and Service Caring for Patient: Provide attending's name and service or practice group.
- Referring Physician: Provide name and contact information (eg, address, phone number) if available.
- Procedures: Include surgery and any invasive diagnostic procedures (eg, lumbar puncture, arteriogram).
- Brief History, Pertinent Physical Findings, and Lab Data: Briefly review the main points of the history, physical, and admission lab tests. Do not repeat what is recorded in the admission note; summarize the most important points about the patient's admission.
- Hospital Course: Briefly summarize in chronologic order the evaluation, treatment, and progress of the patient during the hospitalization. If the patient has more than one problem during the hospitalization, address each problem separately, and within each problem record the events in chronologic order.
- Condition at Discharge: Note whether improved, unchanged, or worse.
- Disposition: Record the location to which the patient is discharged (eg, home, another hospital, nursing home). Give the specific address, if available, if the patient is transferred to another medical institution, and note who will be assuming responsibility for the patient.
- Discharge Medications: List medications, dosing, and refills.
- Discharge Instructions and Follow-up: Note clinic return date, diet instructions, activity restrictions, etc.
- Problem List: List active and past medical problems.
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On-Service Note Also known as a "pick-up note," the on-service note is written by a new member of the team taking over the care of a patient who has been on the service for some time. This type of note is more common on medical services. Make the note brief, summarizing the hospital course to date and showing that the patient's care has been reviewed. The following skeleton includes most of the information needed in an on-service note. - Date of Admission: Specify.
- Admitting Diagnosis: Specify.
- Procedures (with Results) Performed to Date: List.
- Hospital Course to Date: Summarize briefly.
- Brief Physical Examination: Record findings pertinent to the patient's problems.
- Pertinent Lab Data: Summarize key lab tests.
- Problem List: Use problem-numbering system as for the SOAP format (SOAP Note or Daily Progress Note).
- Assessment: Describe how the patient is progressing and the up-to-date assessment of each problem.
- Plan: Outline further testing or therapy planned.
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Off-Service Note If rotating off the service before the patient is discharged, the team member primarily responsible for the patient's care writes an off-service note. The components are identical to those of the on-service note. |
Bedside Procedure Note - Procedure: Lumbar puncture, thoracentesis, etc
- Indications: (eg, R/O meningitis, symptomatic pleural effusion)
- Permission: Note risks and benefits explained and indicate the permission is signed and on chart.
- Physicians: Note physicians and others present and responsible for the procedure.
- Description of Procedure: Indicate type of positioning, prep, anesthesia type and amount (eg, 2 mL 1% lidocaine). Briefly describe technique and instruments used.
- Complications: Note any.
- Estimated Blood Loss (EBL): Note as "minimal," or, if greater, estimate amount lost.
- Specimens/Findings Obtained: (eg, opening pressure for LP, CSF appearance, and tubes sent to lab, etc)
- Disposition: Describe patient's status after procedure (eg, Patient alert and oriented with no complaints; BP stable).
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Preoperative Note The specific items in the preoperative note depend on institutional guidelines, the nature of the procedure, and the age and health of the patient. For example, an ECG and blood set-up may not be necessary for a 2-year-old being treated for a hernia but are essential for a 70-year-old undergoing aortic valve surgery. The following list includes most of the information needed in a preoperative note. - Preop Diagnosis: Record (eg, "acute appendicitis").
- Procedure: Indicate the planned procedure (eg, "exploratory laparotomy").
- Labs: Record results of CBC, electrolytes, PT, PTT, urinalysis, etc.
- CXR: Note results.
- ECG: Note results.
- Blood: Follow institutional guidelines for recommended quantities (eg, T&C 2 units PRBC, blood not needed, etc) (see also Chapter 10).
- History and Physical: See chart.
- Orders: Note any special preop orders, eg, preop colon prep, vaginal douche, prophylactic antibiotics.
- Permission: If completed, write "signed and on chart." If not, indicate plans for obtaining informed consent for the procedure. Note briefly risks and benefits explained.
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Operative Note The operative note is written immediately after a surgical procedure to summarize the operation for those who were not present. The note is meant to complement the formal operative summary dictated by the surgeon. The following list includes most of the information needed in an operative note. Hospitals may produce standardized forms for this type of note. - Preop Diagnosis: Record the reason for the operation (eg, "acute appendicitis").
- Postop Diagnosis: Record the diagnosis based on the operative findings (eg, "mesenteric lymphadenitis").
- Procedure: Specify the operation performed (eg, "exploratory laparotomy").
- Surgeons: List the attending physicians, residents, and students who scrubbed on the case, including their titles, eg, MD, CCIV (clinical clerk, fourth year), MSII (second year medical student). It is often helpful to identify the dictating surgeon.
- Findings: Briefly note operative findings (eg, "normal appendix with marked lymphadenopathy").
- Anesthesia: Specify the type of anesthesia, eg, local, spinal, general, endotracheal.
- Fluids: Record the amount and type of fluid administered during the operation, eg, 1500 mL NS, 1 unit PRBC, 500 mL albumin. This information usually is obtained from the anesthesia records.
- EBL: Record the estimated blood loss. This information is obtained from the anesthesia or nursing records.
- Drains: State location and type of drain, eg, "Jackson Pratt drain in LUQ," "T-tube in midline."
- Specimens: State any samples sent to pathology and the results of examination of any intraoperative frozen sections.
- Complications: Note any complications during or after the operation.
- Condition: Note where the patient is taken immediately after the operation and the patient's condition (eg, "transferred to the recovery room in stable condition").
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Night of Surgery Note (Postop Note) This progress note is written several hours after or the night of surgery. - Procedure: Indicate the operation performed.
- Level of Consciousness: Note whether the patient is alert, drowsy, etc.
- Vital Signs: Record BP, pulse, respiration.
- I&O: Calculate amount of IV fluids, blood, urine output, and other drainage, and attempt to assess fluid balance.
- Physical Examination: Examine the chest, heart, abdomen, extremities, and any other part pertinent to the surgery, and record the findings. Examine the dressing for bleeding.
- Labs: Review lab results obtained since the operation.
- Assessment: Evaluate the postop course thus far (stable, etc).
- Plan: Note any changes in orders.
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Delivery Note Fill in the following: __ -year-old (married or single) G __ now para __, AB __, clinic (note whether patient received prenatal clinic care) patient with EDC __, and prenatal course (specify uncomplicated, or describe any problems). Labor (describe, eg, oxytocin-induced, premature rupture) draped in the usual sterile manner. Under controlled conditions delivered a __ lb __ oz (__ g) viable (specify male or female) infant under __ (specify general, spinal, pudendal, none) anesthesia. Delivery was by __ (specify SVD with midline episiotomy, or forceps, or cesarean section). Apgar scores were __ at 1 min and __ at 5 min (for Apgar scoring, see Appendix Table A 1). Delivery date __; delivery time __. Cord blood sent to lab. Placenta expressed intact with trailing membranes. Lacerations of the __ degree repaired by standard method with good hemostasis and restoration of normal anatomy. - EBL:
- Maternal blood type (MBT):
- HCT (predelivery and postdelivery):
- Rubella titer:
- RPR test, hepatitis B serology, HIV test, and status of other serology or cultures that can affect a mother's or newborn's health:
- Condition of mother:
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Outpatient Prescription Writing The format for outpatient prescription writing is outlined in the following list and illustrated in Figure 2 1. Controlled substances, such as narcotics, require a DEA number on the prescription. Some states require that the controlled substance be written on a special type of prescription pad (see Chapter 22 for controlled drugs indicated by [C]). For security, the DEA number should never be preprinted on a prescription pad but should be written by hand when the prescription is written. |  | Example of an outpatient prescription. As a safety feature DEA numbers should never be preprinted on a prescription form. The "Dispense as Written" statement can vary by state requirements. This statement requests that the pharmacist fill the prescription as requested and not substitute a generic equivalent. |
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Elements of an outpatient prescription include: - Patient's Name, Address, and Age: Print clearly where indicated.
- Date: State requirements vary, but most prescriptions must be filled within 6 mo.
- Rx: Drug name, strength, and type (usually listed as the generic name). Designate "no substitution" if a specific brand name is called for. "Rx" is the abbreviation of the Latin word for "recipe." List the strength of the product (usually in milligrams) and the form (eg, tablet, capsule, suspension, transdermal).
- Dispense: Amount of drug (eg, number of capsules) and time period (eg, 1-mo supply, QS [quantity sufficient])
- Sig: Short for the Latin "signa," which means "mark through" on patient instructions. Abbreviate the instructions or write them in full. Spelling out directions rather than using abbreviations decreases the likelihood of error. A list of frequently used abbreviations follows; see Abbreviations for additional abbreviations.
- ad lib = as much as wanted
- PO = by mouth
- PR = by rectum
- OS = left eye
- OD = right eye
- OU = both eyes
- qd = daily ("qd" is a dangerous abbreviation and should not be used; write out "every day" or "Q day"; see Dangerous Practices)
- PRN = as needed
 = one = two = three- qhs = every night at bedtime
- bid = twice a day
- tid = three times a day
- q6h = every 6 hours
- qid = four times a day. Note that qid and q6h are NOT the same orders: qid means the patient takes the medication four times a day while awake (eg, 8 AM, 12 noon, 6 PM, and 10 PM); q6h means the medication is taken four times a day but by the clock (eg, 6 AM, 12 noon, 6 PM, 12 midnight).
- Refills: How many times this prescription can be refilled
- Substitution: Whether a generic drug be used instead of the one prescribed
Tips for Safe Prescription Writing Legibility - 1. Take time to write legibly.
- 2. Print if doing so would make the prescription more legible than handwriting would.
- 3. Use a typewriter or computer if necessary. Some centers generate prescriptions by computer to eliminate legibility problems.
- 4. Carefully print the order to avoid misreading. There are many "sound alike" drugs and medications that have similar spellings (eg, Celexa and Celebrex).
Dangerous Prescription Writing Practices - 1. Never use a trailing zero.
- Correct: 1 mg; Dangerous: 1.0 mg. If the decimal is not seen, a 10-fold overdose can occur.
- 2. Never leave a decimal point "naked." Correct: 0.5 mL; Dangerous: .5 mL. If the decimal point is not seen, a 10-fold overdose can occur.
- 3. Never abbreviate a drug name. The abbreviation can be misunderstood and have multiple meanings.
- 4. Never abbreviate the word "units." The letter U can be read as a zero (eg, "6 U regular insulin" can be misread as 60 units). Write the order as "6 units regular insulin."
- 5. Never use "qd" (abbreviation for once a day or every day). When poorly written, the tail of the q can make the abbreviation look like "qid," or four times a day. Write out "every day" or "Q day."
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Shorthand for Laboratory Values The method for recording laboratory values is shown in Figure 2 2. |  | Shorthand notation for recording laboratory values. The basic metabolic panel is similar to the SMA-6 except that creatinine is also listed. |
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