STANDARD ADMISSION ORDERS

HENRY FORDMACOMB HOSPITALWARREN CAMPUSSTANDARD ADMISSION ORDERSDATETIMEPRE-PRINTED ORDERS (PAGE 1 OF 3)Orders not valid unless 'x' appears in box, items are circled, blanks are filled in and page signed by a physician01. Admit to Dr. ______________________________________ Diagnosis ________________________________________Medical Management _____________________________ Precautions: MRSA, C-DIFF, VRE Other:______________(Complete additional pre-printed orders for Pneumonia/COPD, CHF, AMI/Chest Pain/Unstable Angina)[ ] 23:59/Observation [ ] Med/Surg [ ] Telemetry [ ] CCU [ ] InPt. Rehab[ ] Private Room / Isolation (document reason) ______________________________________________02. Body Habitus: Ht: ________'_______" Weight: __________ lbs. [ ] Actual [ ] Estimate03. Allergies: [ ] NKA (None) [ ] LatexDrug ____________________ Reaction __________________; Drug _____________ Reaction _______________SAMPLEDrug ____________________ Reaction __________________; Drug _____________ Reaction _______________04. Code Status: [ ] Full [ ] Limited [ ] DNR [ ] Comfort Care ONLY(for any status other than FULL, See Limitation of Treatment Form)05. Condition: [ ] Stable [ ] Fair [ ] Guarded [ ] Critical06. Consultations: Dr. _______________________ for consultation onlyDr. _______________________ for consultation /management of ____________________Dr. _______________________ for consultation and total patient management[ ] Dietician [ ] Social Services [ ] Wound CareEvaluate & Treat: [ ] Physical Therapy [ ] Occupational Therapy [ ] Speech Language [ ] Speech Swallow07. Activities: [ ] As tolerated [ ] Bed Side Commode [ ] Bathroom Privileges w/ Assistance[ ] Up in Chair for Meals [ ] Ambulate 3 x daily [ ] Bed Rest[ ] Other: __________________________________________________________________08. Vitals: [ ] Per Protocol [ ] Every ______ hrs while awake [ ] Every ______ hrs around the clock[ ] Every _______ hrs x _______ then ________________ [ ] Orthostatic VS ___________[ ] Pulse Oximetry _______________ [ ] Daily Weight [ ] Neuro checks every _____ hrs09. Diet: [ ] Regular [ ] Soft [ ] Mechanical Soft [ ] Puree [ ] Liquid (Full / Clear)[ ] Thicken Liquids to (Nectar / Honey / Pudding) Consistency [ ] NPO (Strict / Except Meds)[ ] ADA (2200 / 2000 / 1800 / 1500) kCal [ ] AHA Step 1 (4 / 2) g Na [ ] Bariatric[ ] Renal _______________________ [ ] Fluid Restriction ____________________________[ ] ________________________________________________________________________________[ ] Assist with mealsPhysician Signature:Health Unit Clerk Signature:FORM #: HFBH-69-0100MR-1108 Page 1 of 3Pager:Nurse Signature:WHITE - CHART CANARY - PHARMACY

HENRY FORDMACOMB HOSPITALWARREN CAMPUSSTANDARD ADMISSION ORDERSDATETIMEPRE-PRINTED ORDERS (PAGE 2 OF 3)Orders not valid unless 'x' appears in box, items are circled, blanks are filled in and page signed by a physicianNURSING ORDERS10. [ ] Foley to Gravity [ ] with Urometer [ ] Strict I&O's[ ] Notify Physician if urine output < ________ ml in ________ hrs[ ] Keep Head of Bed elevated > 30 degrees[ ] Precautions: ( Aspiration / Seizure / Fall / Suicide )[ ] DVT Prophylaxis ( Venodynes / Pt. Ambulatory / See Meds ) [ ] Turn pt. every ______ hrs[ ] Dressing Changes every _______________[x] Bring old chart(s) from Health Information Services to patient's current floor[ ] ___________________________________________________________________________________RESPIRATORY ORDERSSAMPLE11. [ ] O2 via N/C @ _______L/m, titrate to Sat >92%[ ] Peak Flow, please record in chart [ ] Daily [ ] Other __________________________________[ ] Incentive Spirometry 10 x every 1 hour while awake[ ] ABG ( x 1 Now / 1 hr after Vent Change / In ) [ ] Bed Side PFT[ ] Albuterol / Atrovent nebulizer solution, unit dose, every __________ hours[ ] Albuterol nebulizer solution, unit dose every 2-4 hours prn dyspnea[ ] Combivent inhaler 2 puffs every 6 hours or _______________________________________________IV FLUIDS12. [ ] IV Saline Lock w/ 0.9% NS flush every shift13. [ ] IV Fluids to be given @ _________ ml / hour; of:[ ] 0.9% NS [ ] D5 / 0.9% NS [ ] LR [ ] D5 / LR [ ] 0.45% NS [ ] D5 / 0.45% NS[ ] D5W [ ] Other: ____________________________________________________________14. [ ] IV Additives: [ ] KCL ________ mEq/L [ ] NaHCO3 ________ mEq/L[ ] 1 Amp MVI, 100 mg Thiamine, 1 mg Folate to First IV Bag Daily[ ] ___________________________________________________________________IMAGING STUDIES15. [ ] ECG ( x 1 Now / with Cardiac Enzymes / In AM / every _________) RE: ______________________16. [ ] CXR ( PA / Lateral / Portable ) ( x 1 Now / In AM ) RE: ____________________________________17. [ ] Abd XR ( AAS / KUB / 2 View ) ( x 1 Now / In AM ) RE: ___________________________________18. [ ] X-Ray of ____________________ ( x 1 Now / In AM ) RE:__________________________________19. [ ] CT Scan ( Head / Chest / Abdominal / Pelvis / Spine / Extremity / Other ________________________)[ ] Contrast ( Without / With / Both ) RE: _______________________________________________20. [ ] 2-D Echo with Color-flow Doppler / M-Mode [ ] Routine [ ] Stat (requires cardiology approval)RE: ______________________________________________________________________________21. [ ] Arterial Doppler ( Carotid / LUE / RUE / LLE / RLE ) RE: __________________________________22. [ ] Venous Doppler (LUE / RUE / LLE / RLE ) RE: __________________________________________23. [ ] U/S ( Renal / Abd / Pelvis / _________________ ) RE: _____________________________________Physician Signature:Health Unit Clerk Signature:Pager:Nurse Signature:FORM #: HFBH-69-0100MR-1108 Page 2 of 3WHITE - CHARTCANARY - PHARMACY