Admission orders

I pretty much do a full assessment and admission before I call for orders, then I ask for what I need. I've called and been told, "I don't even know why the patient is there."

Do you routinely get patients with no orders unless you call the Doc to get them? I guess my first question for the Doc would be "why the heck am I calling you to get the basic orders that you should be here writing without having to be asked?" I don't mind going over an admission orderset over the phone every now and then with a middle of the night direct admit or something like that, but don't let it become routine.

PRN albuterol for asthmatics. Some people forget it on the med rec because they may not need it at home a lot, but they could definitely need it during times of illness. Oxygen if the patients use that. Vital sign/I&O frequencies if not routine on your unit. Sleep medication.

k/mag protocal, basic labs BMP and CBC. Bowel program for the elderly.

I always make sure to ask the patient too if there is anything they want me to tell/ask the doc so I am not having to call them back later. I'd say 90% of our new admits we have to call for the orders. The docs rarely come in to write them.

Hi everyone,

I'm a new nurse and I'm in the process of trying to fine tune my organizational sheets to save time throughout my shift. One thing that I'd like to make more efficient for myself is calling the physician for admission orders on a newly admitted patient. I'm trying to make a checklist of specific things I need to get orders on so nothing is forgotten. Some doctors are great at covering all the bases, but others will only give you what you ask for. I was hoping you could help me try to figure out if I'm missing anything.

What I have so far: Home meds rec, IV fluids, pain/nausea meds if needed, DVT prophylaxis, diet, activity, labs/tests, chems/insulin for diabetic pts. Is there anything else that I should be asking about routinely on admission? I work on a general medical floor.

Thanks.

No, I think you covered it. And thank you for not being one of those nurse who thinks that "bridging orders" means it is ok not to call the doctor until 7 am!