Hopefully your system does not go down but when it does here is your cheat sheet.
1. ALWAYS DATE AND TIME
2. SIGN and print your name and/or doctor number, pager number, etc
3. Make sure the patients name and medical record number or DOB is on the page
A- Admit
D - Diagnosis
C - Condition and Code Status
V - Vitals
A - Allergies
A - Activity
N- Nursing
D - Diet
I - IVF
M - Medications
L - Labs and Tests
S - Special - PT, OT, Case Management
And DATE AND TIME IT
Common Meds after TKA - always check the medication, dose and frequency and the safety profile for the patient.
Abx - Ancef 1 gm q8 (occ Vanco or other)
VTE Prevention - Asa 81 mg BID (or 325mg or eliquis, xarelto, warfarin, enoxaparin, etc)
Scheduled Pain Meds
1. acetaminophen 1000 mg PO q8
2. celebrex 200 mg PO BID
3. sometimes: gabapentin 100 mg PO q8
Breakthru Pain Meds
1. Tramadol 50 mg PO q6 prn mild pain (level 1-5)
2. Oxycodone IR 5 mg PO q6 prn moderate pain (level 6-9)
3. Oxycodone IR 10 mg PO q6 prn severe pain (level 10)
4. sometimes: IV breakthru medications
Bowel - colace 100 mg PO BID
GI - pepcid 20 mg PO BID
Puritis - claritin 10 mg PO q day prn itching
Nausea - zofran 4 mg IV q 6 prn nausea
HOME MEDS!
if diabetic don't forget sliding scale insulin
and DATE AND TIME the orders