SKILLED NURSING FACILITY ADMISSION ORDERS

  1. Admit to (name of facility) under the care of Dr.______(name). Please call to verify orders and for continuing care needs, at Fax # .

2.Admitting Diagnosis: ______

______

Allergies: ______

3.Medications:DoseIndication

______

______

______

______

______

______

______

______

4.Treatments: (Wound care, et cetera)

______

______

______

5.Diet: Regular: ____Mechanical Soft: ____Pureed: ___No Concentrated Sweets: ____

No Added Salt: ____Thickened Liquids: _____Consistency: ______

High Density Foods: ______Frequency: ______Dietary Supplement: ______

Dietitian to evaluate patient: ______Others: ______

6.Weights: Routine: ______Weight patient weekly: ______

7Activity:Independent: ____ Wheelchair ad. lib.:____Remain in bed: ____Up in chair: ____

RNA Program: ____Assisted Ambulation: ______Frequency: ______Duration: ______

8.Activity Therapy: As tolerated and not to interfere with treatment plan.

9.Passes: May go on pass with responsible party: _____with Medications: ___No Passes: ____

10.Labs/other diagnostic tests______

______

11.Appointments at outside facilities______

12.PPD Status:Positive History: _____(Year: _____) None: ____Two step PPD: ______

Chest X-ray, PA and left lateral: ______(Indication:______).

  1. Rehabilitation Evaluation and Treatment as indicated: PT ______

OT: ______ST: ______RT: ______Other: ______None: ______

14.Optometry Eval:Yearly: ______Other: ______None: ______

15.Audiology Eval:Yearly: ______Other: ______None: ______

16Dental Eval:Yearly: ______Other: ______None: ______

17Podiatry Eval:Yearly: ______Other: ______None: ______

18Siderails:Up: Bilateral: ______Left: ______Right: ______None: ______

Indications:For Safety: ______Enablers in positioning: ______

19. Code and Advanced Directives Status: Full Code: ______No CPR: ______

Do Not Hospitalize: ______No Tube Feeding: ______No Antibiotics: ______

Other: ______

20.Blood Pressure Management:For Systolic BP> 180 and or Diastolic> 110. Notify MD: ______

21.Blood Sugar Management:Fingerstick:Frequency: ______

Sliding scale – treat fingerstick blood sugars as follows:

  • Blood sugar greater than ____ but less than ____; give ______units of regular insulin subcutaneously
  • Blood sugar greater than ____ but less than ____; give ______units of regular insulin subcutaneously
  • Blood sugar greater than ____ but less than ____; give ______units of regular insulin subcutaneously
  • Blood sugar greater than ____ but less than ____; give ______units of regular insulin subcutaneously

Notify MD for Blood Sugar < 80 or > 350: ______No Management: ______

22.Fever Management:Notify MD for Temp > 100* _____No Management: ______

23.Immunizations: Yearly Flu Vaccination: ______Pneumovax: ______When: ______

Tetanus Booster: ______When: ______Other: ______

24.Urinary Incontinence Management:Incontinence Brief: ______

Catheter:External: ______Internal: ______Size: ______Indication: ______

Change monthly and prn clogging/leaking ______Proto. to discont. indwelling catheter:______Bladder Training: ______Frequency: ______Incontinence Program: ______

Suprapubic catheter Management: ____Others: ______No Management: ______

25.Bowel Management:Bowel Training: ___Frequency: ______Colostomy Care: ______

For constipation: Encourage fluids _____ Sorbitol 30 cc po daily ____ MOM 30 cc po qhs prn: ______

Metamucil 1 pkt daily in juice ___ Fleets enema per rectum q 3rd day prn: ______

Other: ______No Management: ______

  1. Management of skin conditions: Minor skin tears shall be cleaned with normal saline, edges aligned, and

covered with transparent dressing for 5 days which shall be changed as needed. Monitor for signs of

infection for 5 days; notify clinician if tear fails to respond to treatment.

27.Present patient bill of rights to ____patient ____family member/surrogate/conservator.

28.Additional orders:______

______

Signature of Ordering Physician: ______Date:______

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