I spend most of my time rambling on here on Surviving Gray’s but today I thought I would provide some practical advice. Medical school is heavy on treating disease but light on the practical side of actually making sure your patient receives these treatments. Something every medical student and intern will need to learn is how to admit a patient to the hospital.
So you go see a patient in the emergency room and do the H&P. You present to your attending and you both agree the patient should be admitted. The attending gives you a few words of advice and then promptly disappears. Now what. You need to write the orders to actually admit the patient to the hospital. Like everything in medicine, it is good to have a system. Mine is ADCCCVAANDISML.
A – Admit to
Admit to Dr. Robinson, GMF
First step. Get the patient through the door. First you need to decide what type of bed they are going to. Typical options are
- Observation – the patient’s stay is likely to be less than 24 hours
- GMF – the patient can go to a general med/surg floor without additional monitoring
- Tele – the patient can go to a general med/surg floor but should have telemetry monitoring. Basically any cardiac patient gets this.
- Step-down – you want more frequent monitoring than GMF but the patient doesn’t require ICU
- ICU – the patient’s condition is life threatening and they require the highest level of care
Deciding which of these fits your patient requires experience, your best bet in the beginning is to just ask your attending what they want.
D – Diagnosis
Diagnosis – Acute Cholecystitis, s/p lap chole
C – Condition
Condition – Stable
The condition is your judgement of how sick the patient is and a way to relay this to whoever is looking at the chart. Your options here are essentially stable, guarded and moribund but sometimes people get a bit more creative.
C – Code Status
Code – Full
This is an important one. Do NOT just assume people are full code! It might be awkward but you need to come up with a way to ask people and get them to give you an accurate response. I generally say something like this:
Mrs. X, my final question is one we ask every patient that comes into the hospital. Not because we expect anything bad to happen to you but because we need to know what to do in case of an emergency like your heart stops beating or you can no longer breathe on your own. Would you want us to do everything medically possible to bring you back to life including pumping on your chest, shocking your heart and putting you on a breathing machine?
A lot of people will immediately say “oh hell yeah you keep me going young fella”. Some will explain that they don’t want to be on life support for an extended period time. It is important that at this point you explain to them code status only pertains to the events that happen IMMEDIATELY after a cardiopulmonary arrest and once they are stabilized it comes down to their advanced directive/family to decide how long they stay on life support.
C – Consults
Consult Dr. Schuler, Endocrine Re: Diabetes management, routine
Don’t forget you always need to put a reason for the consult and how urgently it needs to get done.
V – Vitals
Vitals – Per unit protocol
This just tells the nursing staff how often they should be recording vital signs on their patient. Most floors have policies on how often they do it and you can just write “per protocol” but if you want something special like neuro checks or continuous pulse oximetry this is the place to write it. You can also include when they should contact you “please call house office if SBP is >160” although most nurses will just use their own judgement regardless of what you write!
A – Allergies
Allergies – penicillin leads to hives
A – Activity
Activity – Ad Lib
What do you want to allow the patient to do? Feels kinda powerful huh! If you trust your nurse’s judgement it is fine to write ad lib. Otherwise you should be more specific. Some options:
- bedrest with bathroom privileges
- up to chair
- ambulate with assistance
You can be as specific as you want. If your patient has specific instructions on weight-bearing (i.e. no weight-bearing left lower extremity) then write it here. This will help the physical therapist know exactly what they can and cannot do and save you calls!
N – Nursing
Nursing – incentive spirometry 10x per hour
Have something specific you want your nurses to do for/with your patient? Write it here. I always try to add a “please” in there somewhere!
D – Diet
Diet – NPO except medications
Especially important in surgical patients. If you have a patient that is tolerating a full diet make sure you include whether they should be on a special cardiac/diabetic diet.
I – IV Fluids
IVF – LR @ 125 ml/hr
Just a note – make sure you address your patient’s need for IV fluids daily and adjust them accordingly. Remember, they are a medication and they are NOT physiologic!
S – Studies
Studies – HIDA scan re: r/o bile leak
Remember, whenever you order a study you have to give a reason. You can’t just write “do ekg” and your reason cannot be “because I want one goddamnt!”
M – Medications
Medications – SubQ Heparin 5,000 units q8hrs, morphine 1 mg q4 hrs prn pain
I like to divide this up in three categories: prophylactic meds, treatment meds, chronic meds
- Prophylactic meds – this is your DVT or GI prophylaxis, don’t forget it! Every patient should at least have compression boots for dvt prophylaxis. GI prophylaxis is only indicated if the patient is intubated or is on it at home
- Treatment meds – this is what we are actually doing to make the patient feel better for instance pain meds, anti-emetics, breathing treatments. Remember any prn med needs an indication.
- Chronic meds – it is important to go through the list of medications the patient is taking at home and decide which you will give, which you will change, and which you will hold.
L – Labs
Labs – CBC, BMP, Mg, Ph, LFTs in AM
Most hospitals have computerized physician order entry now and many have great order sets that make this easy and prompt you not to forget things. Regardless, I still think it is good practice to go through this acronym yourself every time and make sure you haven’t left anything out. It will help provide excellent patient care and, most importantly, save you calls from the nurses!
Any questions? Ask below.