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