PLACE LABEL HERE

ADMISSION ORDERS

Glancy Rehabilitation Center

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

DIAGNOSIS:______

Secondary Diagnosis: ______

  1. Status: Admit to Glancy Rehabilitation Center for rehabilitation
  1. Allergies: ______
  1. Diet: ______
  1. Vital Signs:  Routine  Orthostatic B/P q ______ Neuro checks q ______
  1. Diagnostic Studies: CXR  EKG  Lower Extremity Venous Doppler (R L Both)

 Other: ______

  1. Labs:Nasal Culture upon admit

CBC, Chem 7 in a.m.

7. Blood Glucose Finger Stick: Before meals and at bedtime Before breakfast and at bedtime

every 6 hrs. Rotating

Sliding Scale Insulin: BG - 100 = # units Humalog insulin subcutaneous prn for BG 160

30 (Call physician if BG greater than 400 mg/dl)

  1. Activity: ______
  1. Weight Bearing Precautions: ______
  1. Devices: CPM  Knee Immobilizer (R L Both)  Cervical Collar

 Splint to ______

 Cold Pack Machine to _____  Back Brace  TLSO on when:  Out of Bed  at all times

  1. Other Precautions:  Hip  Swallowing  Cardiac  Hypertension  Seizure  Spinal

Copy to pharmacyOrder writer’s initials ______

*3-16197* FORM 3-16197 REV. 10/2016 Page 1 of 3

PLACE LABEL HERE

ADMISSION ORDERS

Glancy Rehabilitation Center

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked. Initial all handwritten order modifications and the bottom of each page indicated (multipage).

  1. Therapy
  • Physical Therapy:

Copy to pharmacyOrder writer’s initials ______

FORM 3-16197 REV. 10/2016 Page 1 of 3

PLACE LABEL HERE

ADMISSION ORDERS

Glancy Rehabilitation Center

PT Evaluation and Treat

Muscle Strengthening Exercises

PT ROM Exercises: ______

PT Balance

PT Coordination

PT Endurance Training

Modalities: ______

PT Gait and / or wheelchair Training

PT Transfer Training

Patient/Family Education

Muscle Re-Education of ______

Community Re-Integration

Copy to pharmacyOrder writer’s initials ______

FORM 3-16197 REV. 10/2016 Page 1 of 3

PLACE LABEL HERE

ADMISSION ORDERS

Glancy Rehabilitation Center

Copy to pharmacyOrder writer’s initials ______

FORM 3-16197 REV. 10/2016 Page 1 of 3

PLACE LABEL HERE

ADMISSION ORDERS

Glancy Rehabilitation Center

  • Occupational Therapy:

Copy to pharmacyOrder writer’s initials ______

FORM 3-16197 REV. 10/2016 Page 1 of 3

PLACE LABEL HERE

ADMISSION ORDERS

Glancy Rehabilitation Center

OT Evaluation and Treat

OT ADL / IADL Training

OT ROM Exercises

Muscle Re-Education of ______

UE Strengthening

Community Re-Integration

Patient/Family Education

Splinting

Modalities: ______

 PT Gait training

 Visual / Perceptual

Copy to pharmacyOrder writer’s initials ______

FORM 3-16197 REV. 10/2016 Page 1 of 3

PLACE LABEL HERE

ADMISSION ORDERS

Glancy Rehabilitation Center

  • Speech Language Pathology:

Evaluate and Treat

Expressive LanguageTraining

Language Comprehension Training

Speech Intelligibility Training

Cognitive Retraining

Dysphagia Evaluation and Treatment

Patient/Family Education

Vocal Training

Copy to pharmacyOrder writer’s initials ______

FORM 3-16197 REV. 10/2016 Page 1 of 3

PLACE LABEL HERE

ADMISSION ORDERS

Glancy Rehabilitation Center

  • Therapeutic Recreation:

Leisure and Community Treatment

  1. Neuropsychology

Copy to pharmacyOrder writer’s initials ______

FORM 3-16197 REV. 10/2016 Page 1 of 3

PLACE LABEL HERE

ADMISSION ORDERS

Glancy Rehabilitation Center

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

14. VTE Prophylaxis:Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg or age > 75)

orLovenox (enoxaparin) 40 mg SQ daily at 1700 (30 mg if CrCl < 30 ml/min)

and/orMechanical devices:  Plexi-pulses  SCDs

15. All oral medications given  PO OR  via tube

PRN MEDICATIONSSee policy 520-06 for range orders and pain intensity guidelines.

16. Mild pain/temp>100.5F/HA:  Tylenol (acetaminophen) 325-650 mg po/via tube q 4 hrs prn

17. Indigestion:  Maalox XS (aluminum/magnesium/simethicone) 30 ml po/via tube four times daily prn

18. Stool Softener:  Colace (docusate) 100 mg po/via tube twice daily prn

19. Constipation:

If no Bowel Movement (BM) in past 72 hrs, give:

Senokot-S (docusate/senna) 1 tablet po/via tube at bedtime nightly prn

If still no BM after 12 hrs., give:

Lactulose 30 ml po/via tube twice daily prn

AND

Dulcolax (bisacodyl) 10 mg suppository per rectum q day prn

If still no BM after 24 hrs., give:

Enemeez (docusate sodium) 1 enema per rectum q day @ 1800 prn

20. Urinary Retention Protocol Glancy Rehabilitation Center (# 33775)

21. If patient has CVC line, Central Venous Catheter Care Orders (# 32657)

22. If patient has a PICC line, PICC Post Insertion Orders (# 16755)

23.  Electrolyte Replacement Protocol Glancy Rehabilitation Center (# 33774)

I have reviewed and considered the patient’s home medications as part of my admission orders.

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-16197 REV. 10/2016 Page 1 of 3