Direct Admission Orders
PLACE LABEL HERE
DIRECT ADMISSION
ORDERS
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
Attending Physician: ______
1. Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission?
q Yes, admit as inpatient, proceed to # 2 q No, place in observation
2. If admitted as inpatient, Inpatient Physician Certification:
Diagnosis: ______
Level of Care: q Critical q Intermediate q Acute Care Location/Specialty Unit Preference___
3. q Telemetry: If patient Medical/Surgical, must complete form # 36084
4. q Isolation: q Contact q Droplet q Airborne For: ______
5. Consults: ______
6. Special needs: q Bariatric Beds (> 181.8 kg (400 lbs) q Dialysis q Sitter/1013
7. Diagnostics : q CBC q PT/PTT q TSH q CMP q Urinalysis
q Troponin
q CXR PA/lateral on admission, Reason______, to be read by______
q EKG on admission, Reason______, to be read by______
q Quantitative hCG for any menstruating female ≥ 12 y/o
q Other: ______
8. Vital signs per unit routine or q ____ hrs
9. q Glucose finger stick ac & hs or q ____ hrs
10 Diet: q Regular q Cardiac q Diabetic______calories q Renal q Other: ______
11. Activity (advance as tolerated): Bed rest or q Up ad lib q BSC q BRP
12. q Please call Physician/Provider on arrival to the floor
MEDICATION ORDERS:
13. q INT q IVF: ______IV at ______ml/hr
14. ______
15. ______
16. ______
ADDITIONAL ORDERS:
______
______
______
______
Date Time Physician Signature PID Number
Copy to pharmacy
*1-39006* FORM 39006 INITIATED 08/2015 Page 1 of 1