What is a systematic way of writing orders for patients in the Emergency Room (ER)?

Systematic Approach to Writing Orders in the Emergency Department

Use a structured mnemonic framework (ADC VANDALISM) to systematically write ER orders, ensuring all critical components are addressed while maintaining clear responsibility boundaries between emergency and admitting physicians.

Core Ordering Framework

The most practical systematic approach uses the ADC VANDALISM mnemonic to ensure comprehensive order writing:

• Admit/Discharge/Transfer status
• Diagnosis
• Condition/Acuity level
• Vital signs frequency
• Activity level
• Nursing instructions
• Diet
• Allergies
• Labs and diagnostic studies
• IV fluids
• Special medications
• Monitoring parameters

This structured approach prevents omissions and creates a logical flow for order entry 1, 2.

Responsibility Delineation in Order Writing

Emergency physicians are responsible for orders only while the patient is physically present in the ED under their care 3.

For Admitted Patients

• The admitting physician assumes responsibility for patient care after accepting the admission, regardless of the patient's physical location in the hospital 3
• When compelled to write orders extending beyond ED treatment, emergency physicians may write transition orders that include only essential treatment and assessment parameters required before the admitting physician prepares formal admission orders 3
• Hospital policies must define an appropriate timeframe for the admitting physician to see the patient and prepare admission orders 3

Common Pitfall to Avoid

Never write comprehensive admission orders as an emergency physician—this creates ambiguity about care responsibility and potential patient safety issues 3. Limit transition orders to immediate stabilization needs only.

Electronic Order Entry Best Practices

Order Set Utilization

• Focus on high-value order sets: The top 20% of order sets account for 90% of all usage, with ADT (admission/discharge/transfer) and perioperative order sets representing the highest utilization at 27.6% and 24.2% respectively 2
• Condition-specific order sets for chest pain/acute coronary syndrome, peripartum care, and diabetes account for over half of condition-specific usage 2
• Task-specific order sets for insulin management, angiography, and arthroplasty procedures are most frequently used 2

Clinical Decision Support Integration

Streamlined clinical decision support systems (CDSS) should incorporate patient data at the point of electronic prescribing, including laboratory results, renal function, medical history, allergies, and local recommendations 3.

• CDSS can reduce antibiotic usage and length of stay when properly implemented 3
• Avoid information overload by designing ED-specific streamlined systems 3
• Be aware that CDSS may lead to over-reliance on automation 3

Antimicrobial Ordering Specifics

Structured Antimicrobial Orders

Use antimicrobial order forms (paper or electronic) that require completion with subsequent pharmacy approval to facilitate guideline implementation 3.

Key components to include:

• Patient renal function for dose adjustment 3
• Documented allergies 3
• Culture specimens obtained prior to first antibiotic dose to enable subsequent de-escalation 3
• Local resistance patterns and institutional recommendations 3

Critical Action

Obtain adequate culture specimens before administering antibiotics so admitting physicians have pathogen identification and susceptibility results for targeted therapy 3.

Discharge Order Components

Essential Discharge Elements

Structured discharge instructions must contain all relevant information in understandable format 3:

• Diagnosis and condition explanation in patient-centered language 3
• Medication instructions with specific "patient-centered" directions (exact number of pills at exact times) rather than vague frequency instructions 3
• Return precautions with specific symptoms requiring immediate return 3
• Follow-up appointments with contact information 3

Medication Dosing Clarity

• Use explicit dosing instructions rather than frequency-based directions (e.g., "Take 2 tablets at 8 AM and 2 tablets at 8 PM" instead of "Take twice daily") 3
• Provide written materials in addition to verbal instructions to improve recall 3
• Consider pictograms for patients with low literacy 3

Order Writing Sequence for New ER Patients

1. Document patient identification: Name, date of birth, weight 4
2. Specify acuity level and monitoring frequency: Vital signs q15min, q1h, q4h based on severity 1
3. Order diagnostic studies: Labs, imaging, cultures (before antibiotics) 3
4. IV access and fluids: Type, rate, additives 1
5. Medications: With specific indications, doses adjusted for renal/hepatic function 3
6. Activity restrictions: Bed rest, bathroom privileges, fall precautions 1
7. Diet orders: NPO, clear liquids, regular as appropriate 1
8. Nursing protocols: Pain reassessment, neuro checks, intake/output 1
9. Disposition planning: Admission, discharge, observation 3

Quality Assurance Measures

• Review and update order sets periodically, especially when regulations or guidelines change 4
• Ensure forms use clear, understandable language appropriate for patient literacy level 3, 4
• Document rationale for treatment limitations and discussions with patients or surrogates 4
• Provide patients with copies of all discharge instructions and prescriptions 3, 4