Direct Admission Orders - Emory Johns Creek Hospital

Direct Admission Orders
Call Nursing Supervisor for bed assignment: 678-474-8234
NOTE: Orders with a “” are choices and are NOT ordered unless checked.
Last Name
Patient Information
Admitting Physician
Physician Information
First Name MI Phone Number Fax Number NPI Number
Birthdate
Admit Inpatient Observation
Location:
Medical Floor ICU
Surgical Floor OB
DIAGNOSES:
1) 2) 3) 4)
ALLERGIES:
NKDA
Medication Intolerances:
ACTIVITY:
Ad lib
Bedrest
VITAL SIGNS:
q shift
q4h
Bathroom privileges Bedside Commode
per ICU protocol Neuro Checks q ___ hours
HOB > 30 degrees Assist patient with all movement
Sit patient on edge Ambulate patient q shift
NURSING:
of bed q shift
Fall Precautions
Daily weights
Diapers
Strict I’s & O’s
DIET:
Foley catheter
Regular
Mechanical Soft
Accu checks: qac & qhs q 4 hours (if NPO)
Pureed
Full Liquids
Clear Liquids Cardiac (low fat, low chol) Other No Caffeine ADA______calories
Low Na ___ grams Low residue, low fiber Lactose restricted Protein restriction ________ grams N
For Hemodialysis Patients:
IVF:
(100 gram Protein, 2 gram Sodium,
Fluid with additives @
Low Potassium, Low Phosphorus)
mL/hour for
duration
Other:
INT – flush q shift with saline
Other:
DIAGNOSTIC TESTS: Obtain Stat AM PM
Chem. Basic Type and Screen ABG
Chem. Comp CKMB/Trop q8 h x 2 Blood Culture x 2
CBC with diff Urinalysis with microscopy EKG
PT, INR PTT Urine Culture CXR PA & lateral
Other Other CXR – Portable
CONSULT:
MEDICATIONS:
Physician Signature: Date: Time:

Registration Information
We want your registration process to go as smoothly as possible. Please remember to bring with you at
the time of registration the following items:
All active insurance cards
Picture ID
Living Will, if you have one
Physician Orders
Patients are responsible for all financial liabilities including co-payments, deductibles, and out-of-pocket
expenses at the time of registration or at the time of discharge for emergency admissions. If the exact
dollar amount has not been determined, you will be asked to pay the estimated amount and will be billed
for the remainder.
If you are being admitted, please leave your valuables at home for safekeeping. You will be required to
sign the following:
Conditions of Admission
Authorization for Release of Information
Consent to Treatment
If you are a Medicare recipient, you will be required:
To complete the Medicare Secondary questionnaire
To sign the Medicare Rights Statement (Inpatient Admissions Only)
Frequently called numbers: Main 678-474-7000
Registration/Admissions 678-474-7099
Billing 678-421-7062
Nursing Supervisor 678-474-8234
Please bring this physician order form with you. You may not be admitted without a written order from
your doctor.
Directions
From I-85: Take Pleasant Hill Road exit. Travel west on
Pleasant Hill for 5 miles until it becomes State Bridge Rd.
Turn right onto Medlock Bridge Road (GA 141
N/Peachtree Pkwy). Go 3.5 miles and turn left onto West
Johns Crossing. Hospital is less than half a mile on the
left.
From 400: Exit 10 (GA 120/Old Milton Pkwy) - Merge
onto GA 120 E towards Duluth. Turn left onto Kimball
Bridge (GA 120E). Turn left onto Jones Bridge Rd. Turn
right onto Sargent Road. Sargent Rd. becomes McGinnis
Ferry Rd. Turn right onto West Johns Crossing. Hospital
is less than a quarter mile on the right.
Address: 6325 West Johns Crossing, Johns Creek, GA 30097