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Updated 5/5/11

(Suggestions: write orders on hospital order sheet, use this format as reminder)

A-dmit to:..list: facility and physician who will follow.
D-iagnosis:..list: the hospital generated diagnosis,
  (do this only if a DC summary will not accompany patient) Goal is to send all patients with DC summary when possible
C-ondition &
-ode status
if known (If a DC summary will not accompany patient:list status at discharge of problems treated in hospital.)
A-llergies... give adverse reaction if known
V-ital signs.. VS & weights (frequency) sit-stand BP's (if pertinent)
  Sao2? criteria for calling & who to call
  (NH's usually have a routine of VS frequency such as weekly or monthly
A-ctivity level. activities orders PT?  OT?
  (write orders for rehab, orders should list: reasons for therapy and goal.) e.g. Gait/Balance & restrengthening  for post-hip fx to regain independent ambulation.
N-ursing orders:. e.g. skin care orders, ambulation, etc.
D-iet:... diet (consistency, type) (note many NH residents need only regular diets)
  feeding instructions for swallowing disorders
  Speech therapy consults (if swallowing disorders are suspected.)
   include daily fluid by shift (po or IV) if pertinent.
I-V fluids........ write only if needed, be sure receiving facility
can do IV's.

Fluid goals (oral) I & O's needed?
M-eds............. try to write for q day or bid dosing when possible, crushed? liquids?
  provide indications for each med. e.g. metoprolol (CHF)
  write # days for antibiotics remember any respiratory meds
  For narcotics or continuous meds, fax the orders in advance to the facility to avoid interruptions in therapy.
  eye drops? skin care?
L-abs.............. write indications for labs. (Most NH's have routine lab days, if not critical write " next lab day" or in generalities such as "1-2 weeks". Avoid labs on Fridays & weekends if possible.
  write "who to call" with results or where to send results.
S-pecifics:...... Respiratory therapy? O2? Nebs?
  F/U appointments, who and when?
  If NH Re-admit: Resume: previous lab or therapies?
  Accuchecks SSI? renew previous meds?


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