Resource for written orders

[porktaco]

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Disclaimer: This is going to sound like an incredibly ridiculous and naive question to the Old Guard of surgeons (and residents at places with no EMR). I know how stupid I'm about to sound. Please indulge me.

I am a graduating MS4 at a school with global Epic EMR access. Everyone (attendings, residents, nurses, techs) uses Preference Lists, Smart Sets, and templates to autopopulate notes and orders.

I am joining a surgery program that is mostly paper-based (for now).

Is there a centralized resource of templates (or ultra-basic mnemonics) you use to write basic notes and orders like admit orders and discharge summaries?

How do you follow up on whether orders were completed?

 

[Pir8DeacDoc]

https://www.google.com/search?q=poc...oAA&biw=768&bih=928#biv=i|0;d|OWDvp9ISQQhE3M:


That should help

sorry that just showed my google search. I could not remember that Maxwell book... It was helpful before my hospital had EMR

http://http://www.maxwellbook.com/

 

[badasshairday]

For admission orders:

ADCVAANDIML (for Admit, Diagnosis, Condition, Vital signs, Allergies, Activity, Nursing, Diet, IV fluids, Medications, Labs/procedures)


For discharge orders:
They are simple, like, 1. Discharge home today 2. follow up in Dr Surgeon's clinic in 2 weeks 3. follow up with PCP within one month patient to call for appointment 4. dc peripheral iv 5. activity limitation, 10 pound lifting restriction. 5. discharge diet: soft

 

[deleted50541]

For admission orders:

ADCVAANDIML (for Admit, Diagnosis, Condition, Vital signs, Allergies, Activity, Nursing, Diet, IV fluids, Medications, Labs/procedures)

If you remember this as "ADC VANDALISM", you'll never forget anything on your admit/post-op orders. The added 'S' is for studies, e.g. X-ray, CT, etc.

Your specific institution may have a required template they want you to follow for dictating discharge summaries. Best to find out sooner than later.

As for order follow-up, that'll be one of your primary tasks as an intern. Write EVERYTHING down you need to follow-up on so you don't forget. Be obsessive about checking labs/talking to the pharmacy (a friendly phone call can often speed up delays), call the nurses' station/talk to the nurse about specific orders, and/or do it yourself if you've got time.

 

[45408]

If you remember this as "ADC VANDALISM", you'll never forget anything on your admit/post-op orders. The added 'S' is for studies, e.g. X-ray, CT, etc.

Your specific institution may have a required template they want you to follow for dictating discharge summaries. Best to find out sooner than later.

Agree for both. That's the acronym I use, and I've got a little laminated card they hand out for dictation requirements.