Inpatient reference · Admission order sets

Admission order sets

Complete admission orders for 21 core inpatient diagnoses — 17 adult conditions plus weight-based pediatric sets (DKA, sepsis, asthma, seizures). Every set covers all 12 domains: disposition, medications, fluids, labs, imaging, consults, monitoring, VTE prophylaxis, diet, activity, nursing orders, and discharge criteria. Use the AI panel to adapt the standard set to your specific patient.

Educational reference — verify every order against institutional protocol, pharmacy, and attending guidance before signing. Doses assume normal renal/hepatic function unless stated.

Standard order set

Community-acquired pneumonia

1Admission / disposition

Admit to: Medicine, ward bed — attending [name]. Anticipated status: Inpatient
Diagnosis: Community-acquired pneumonia (J18.9) — document severity by CURB-65 / PSI
Condition: [stable / guarded] · Code status: [confirm and document]
Allergies: [document agent + reaction type BEFORE first antibiotic dose]
ICU triage: ≥ 3 IDSA/ATS minor criteria, vasopressor need, or mechanical ventilation

2Medications

Ceftriaxone 1 g IV q24h PLUS azithromycin 500 mg IV/PO q24h (standard ward CAP)
QT prolongation / macrolide allergy: doxycycline 100 mg PO/IV q12h in place of azithromycin
Monotherapy alternative: levofloxacin 750 mg IV/PO q24h
Add MRSA coverage (vancomycin 15–20 mg/kg IV q8–12h) ONLY if prior MRSA, recent hospitalization + IV abx, or cavitary disease — send MRSA nares PCR to de-escalate
Add Pseudomonas coverage (swap ceftriaxone → cefepime 2 g IV q8h or pip-tazo 4.5 g IV q6h) ONLY if prior Pseudomonas or structural lung disease
Acetaminophen 650 mg PO q6h PRN fever > 38.3 °C or pain (max 3 g/day; 2 g if cirrhosis)
Albuterol 2.5 mg nebulized q4h PRN wheeze
First antibiotic dose within 4 h of admission — timestamp it

3IV fluids

NS or LR at 75–100 mL/h ONLY if poor PO intake or pre-renal AKI — reassess each shift
Hold maintenance fluids if HF history or drinking well — saline lock instead

4Labs

CBC with differential, BMP now and q AM
Blood cultures ×2 BEFORE antibiotics — required if severe CAP, immunocompromised, or septic
Sputum Gram stain + culture (before antibiotics if obtainable)
Legionella + pneumococcal urinary antigens (severe CAP or epidemiologic risk)
Influenza / SARS-CoV-2 PCR in season; procalcitonin optional to guide duration
Lactate if sepsis criteria met
MRSA nares PCR if vancomycin started (NPV ~99% — use it to de-escalate)

5Imaging / diagnostics

CXR PA/lateral (if not done in ED) — document infiltrate location
Repeat CXR only for clinical worsening — no routine follow-up film inpatient
CT chest if concern for empyema, abscess, or non-resolving pneumonia
Ultrasound if effusion more than trace — thoracentesis if > 1 cm layering

6Consults

Pulmonology: complicated effusion, empyema, abscess, or non-resolving infiltrate
Infectious diseases: immunocompromised host or resistant organism
Respiratory therapy: neb protocol + incentive spirometry teaching

7Monitoring

Vitals q4h; continuous pulse oximetry while on supplemental O2
Titrate O2 to SpO2 ≥ 92% (88–92% if CO2 retainer) — RT wean protocol
Escalate for RR > 24, SpO2 < 90% on current O2, or new confusion

8VTE prophylaxis

Enoxaparin 40 mg SC q24h (CrCl ≥ 30 mL/min)
Heparin 5,000 units SC q8h if CrCl < 30 or dialysis
SCDs if pharmacologic prophylaxis contraindicated (active bleed, platelets < 50k)

9Diet

Regular diet as tolerated; advance from clears if nauseated
Bedside swallow screen before PO if aspiration suspected (elderly, neuro disease, witnessed aspiration)

10Activity

Up ad lib with assistance; ambulate at least TID
Incentive spirometry 10 breaths q1h while awake

11Nursing orders

Strict intake & output each shift
Notify MD: T > 38.5 °C, SBP < 90, HR > 120, RR > 24, SpO2 < 90%, new confusion
Daily assessment for IV-to-PO antibiotic switch (afebrile, improving, tolerating PO)

12Discharge criteria

Clinically stable ×24 h: T < 37.8 °C, HR < 100, RR < 24, SBP ≥ 90, SpO2 ≥ 90% on room air or baseline O2
Tolerating PO — switched to oral antibiotics (total course 5 days if stable by day 3; longer for MRSA/Pseudomonas)
Mentation at baseline; reliable outpatient follow-up within 1 week
Pneumococcal + influenza vaccination addressed; smoking cessation counseled

Customize to my patient

CAP · Claude 4.5

The AI takes the standard CAP set and adapts it — renal dosing, allergy swaps, weight-based doses, home-med conflicts, comorbidity adjustments. It never invents facts you didn't give it.

Patient details

RxFlow Review · Admission order set — Community-acquired pneumonia

Educational reference — verify with pharmacy and institutional protocol before signing.

ADMISSION ORDER SET — Community-acquired pneumonia

01. ADMISSION / DISPOSITION
  [ ] Admit to: Medicine, ward bed — attending [name]. Anticipated status: Inpatient
  [ ] Diagnosis: Community-acquired pneumonia (J18.9) — document severity by CURB-65 / PSI
  [ ] Condition: [stable / guarded] · Code status: [confirm and document]
  [ ] Allergies: [document agent + reaction type BEFORE first antibiotic dose]
  [ ] ICU triage: ≥ 3 IDSA/ATS minor criteria, vasopressor need, or mechanical ventilation

02. MEDICATIONS
  [ ] Ceftriaxone 1 g IV q24h PLUS azithromycin 500 mg IV/PO q24h (standard ward CAP)
  [ ] QT prolongation / macrolide allergy: doxycycline 100 mg PO/IV q12h in place of azithromycin
  [ ] Monotherapy alternative: levofloxacin 750 mg IV/PO q24h
  [ ] Add MRSA coverage (vancomycin 15–20 mg/kg IV q8–12h) ONLY if prior MRSA, recent hospitalization + IV abx, or cavitary disease — send MRSA nares PCR to de-escalate
  [ ] Add Pseudomonas coverage (swap ceftriaxone → cefepime 2 g IV q8h or pip-tazo 4.5 g IV q6h) ONLY if prior Pseudomonas or structural lung disease
  [ ] Acetaminophen 650 mg PO q6h PRN fever > 38.3 °C or pain (max 3 g/day; 2 g if cirrhosis)
  [ ] Albuterol 2.5 mg nebulized q4h PRN wheeze
  [ ] First antibiotic dose within 4 h of admission — timestamp it

03. IV FLUIDS
  [ ] NS or LR at 75–100 mL/h ONLY if poor PO intake or pre-renal AKI — reassess each shift
  [ ] Hold maintenance fluids if HF history or drinking well — saline lock instead

04. LABS
  [ ] CBC with differential, BMP now and q AM
  [ ] Blood cultures ×2 BEFORE antibiotics — required if severe CAP, immunocompromised, or septic
  [ ] Sputum Gram stain + culture (before antibiotics if obtainable)
  [ ] Legionella + pneumococcal urinary antigens (severe CAP or epidemiologic risk)
  [ ] Influenza / SARS-CoV-2 PCR in season; procalcitonin optional to guide duration
  [ ] Lactate if sepsis criteria met
  [ ] MRSA nares PCR if vancomycin started (NPV ~99% — use it to de-escalate)

05. IMAGING / DIAGNOSTICS
  [ ] CXR PA/lateral (if not done in ED) — document infiltrate location
  [ ] Repeat CXR only for clinical worsening — no routine follow-up film inpatient
  [ ] CT chest if concern for empyema, abscess, or non-resolving pneumonia
  [ ] Ultrasound if effusion more than trace — thoracentesis if > 1 cm layering

06. CONSULTS
  [ ] Pulmonology: complicated effusion, empyema, abscess, or non-resolving infiltrate
  [ ] Infectious diseases: immunocompromised host or resistant organism
  [ ] Respiratory therapy: neb protocol + incentive spirometry teaching

07. MONITORING
  [ ] Vitals q4h; continuous pulse oximetry while on supplemental O2
  [ ] Titrate O2 to SpO2 ≥ 92% (88–92% if CO2 retainer) — RT wean protocol
  [ ] Escalate for RR > 24, SpO2 < 90% on current O2, or new confusion

08. VTE PROPHYLAXIS
  [ ] Enoxaparin 40 mg SC q24h (CrCl ≥ 30 mL/min)
  [ ] Heparin 5,000 units SC q8h if CrCl < 30 or dialysis
  [ ] SCDs if pharmacologic prophylaxis contraindicated (active bleed, platelets < 50k)

09. DIET
  [ ] Regular diet as tolerated; advance from clears if nauseated
  [ ] Bedside swallow screen before PO if aspiration suspected (elderly, neuro disease, witnessed aspiration)

10. ACTIVITY
  [ ] Up ad lib with assistance; ambulate at least TID
  [ ] Incentive spirometry 10 breaths q1h while awake

11. NURSING ORDERS
  [ ] Strict intake & output each shift
  [ ] Notify MD: T > 38.5 °C, SBP < 90, HR > 120, RR > 24, SpO2 < 90%, new confusion
  [ ] Daily assessment for IV-to-PO antibiotic switch (afebrile, improving, tolerating PO)

12. DISCHARGE CRITERIA
  [ ] Clinically stable ×24 h: T < 37.8 °C, HR < 100, RR < 24, SBP ≥ 90, SpO2 ≥ 90% on room air or baseline O2
  [ ] Tolerating PO — switched to oral antibiotics (total course 5 days if stable by day 3; longer for MRSA/Pseudomonas)
  [ ] Mentation at baseline; reliable outpatient follow-up within 1 week
  [ ] Pneumococcal + influenza vaccination addressed; smoking cessation counseled

Educational reference — verify every order against institutional protocol, pharmacy, and attending guidance before signing.