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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.
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- 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 stands for Subjective, Objective, Assessment, and
Plan. A sample ICU progress note is reviewed in Chapter 20.
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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?
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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.
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A is the place for recording the Assessment of the patient. Evaluate
the data, and record any conclusions drawn.
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P is where the Plan for
the day is recorded. Include any new lab tests or medications, changes
or additions to previous orders, ...