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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.

  • 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

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 ...

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