Direct Admission Orders
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PLACE LABEL HERE DIRECT ADMISSION ORDERS
The following orders will be implemented. Orders with a “” 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? Yes, admit as inpatient, proceed to # 2 No, place in observation 2. If admitted as inpatient, Inpatient Physician Certification: Diagnosis: ______Level of Care: Critical Intermediate Acute Care Location/Specialty Unit Preference___ 3. Telemetry: If patient Medical/Surgical, must complete form # 36084 4. Isolation: Contact Droplet Airborne For: ______5. Consults: ______6. Special needs: Bariatric Beds (> 181.8 kg (400 lbs) Dialysis Sitter/1013 7. Diagnostics : CBC PT/PTT TSH CMP Urinalysis Troponin CXR PA/lateral on admission, Reason______, to be read by______ EKG on admission, Reason______, to be read by______ Quantitative hCG for any menstruating female ≥ 12 y/o Other: ______8. Vital signs per unit routine or q ____ hrs 9. Glucose finger stick ac & hs or q ____ hrs 10 Diet: Regular Cardiac Diabetic______calories Renal Other: ______11. Activity (advance as tolerated): Bed rest or Up ad lib BSC BRP 12. Please call Physician/Provider on arrival to the floor MEDICATION ORDERS: 13. INT 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