Admit and Transfer orders
The full admission and transfer order set, line by line, in the order you write it.
Write these in the same sequence every single time. The order is not arbitrary: it moves from where the patient is going, through what they are allowed to do, to what you want to be told about. Do it the same way on every patient and you stop forgetting things at 2 a.m.
Floor, room, service, attending, residents.
List in order of priority.
Good, stable, fair, guarded, critical.
Do not put the condition as stable. Use "fair." If they are stable, send them home.
q4h, q shift, routine, or per ICU protocol.
Ad lib, bed rest, up to chair, ambulate tid.
Regular, ADA (diabetic) 1600 calorie, low sodium, clear liquid, NPO.
Strict, routine, or ad lib.
0.9 percent normal saline at 120 mL/h, or specify a rate over a set number of hours.
Foley to gravity, nasogastric tube to intermittent suction, and so on.
Antibiotics, anticoagulants, antiemetics, insulin, oxygen, pain medications. Do not forget DVT prophylaxis and the home medications you intend to continue.
Specific medications and the reaction, or NKDA.
CBC, chemistries, x-rays, EKGs, pulse oximetry.
Arterial line, non-invasive blood pressure, CVP, pulse oximetry, telemetry.
Nebulizer treatments, endotracheal suctioning, incentive spirometry.
Dressing changes, compression stockings.
Notify the house officer if the blood pressure is over 150/100, the temperature is over 101 degrees Fahrenheit, and so on. Set these thresholds deliberately. Set them too tight and you will be paged all night about numbers you do not care about.
"Stable" is a word with a specific meaning to families, to the press and to a jury, and it implies the patient does not need to be in the hospital. If they are genuinely stable, they can go home. Write "fair" and you have described the same patient without arguing against your own admission.