A requiem for handwritten admitting orders

When I first learned to take care of patients in the hospital, as a third-year medical student, we used a mnemonic to help us remember what to order when a patient was first admitted. Patients would come in to the hospital from a doctor’s office or from the emergency room and the nurses needed a set of orders to know what to do for the patient. The mnemonic we used was “ABC DAVID.”

This is how it worked:

  1. Admit: to medical surgical unit
  2. Because: diagnosis — congestive heart failure
  3. Condition: guarded
  4. Diet: sodium restricted
  5. Allergies: no known drug allergies
  6. Activity (sorry, 2 As): bedrest with bathroom privileges
  7. Vital signs: every 4 hours while awake
  8. Investigations: chest x-ray, morning labs — chemistry panel and blood count
  9. Drugs: digoxin, a diuretic, potassium, a beta blocker, maybe insulin or blood pressure medications, acetaminophen for pain, something mild for sleep, if needed.

It worked pretty well. It did allow me to forget certain things that I really didn’t want to forget, like having the nurses measure accurate intake and output (food, water, IV fluids, poop, pee and vomit), care of catheters or nasogastric tubes, but it made sure that I didn’t forget the main things.

Today, I admitted a patient with congestive heart failure and used our hospital’s brand new computerized order entry system with its brand new congestive heart failure admission order protocol. It’s huge compared to ABC DAVID, who seemed like a strapping lad a mere quarter of a century ago.

It includes the medications that experts have determined from large studies to be necessary for optimal treatment of congestive heart failure, the tests that must be done to adequately diagnose congestive heart failure, plus the other things that we think should be done on everyone who is admitted to the hospital including vaccination for flu and pneumonia, smoking cessation, prevention of blood clots in the legs, plus numerous medications that patients are felt to need even if they don’t take them at home, including laxatives, sedatives and nicotine replacement.

I must use my rudimentary knowledge of hospital billing to characterize the patient as being an inpatient or on observation. End of life wishes must be documented. Also, of course, ABC DAVID is buried inside the order set.

Even though the computer has various habits that I find irritating, like wanting medication orders to be written in a specific way and notifying me of medication interactions that I am already aware of or which are of no clinical significance, I was grateful to have a way to remember all of this stuff that is, apparently, important and necessary. My brain is too small to hold all of these orders and even too small to hold a mnemonic large enough to remind me of all of these things.

Orders are different, of course, for congestive heart failure and community acquired pneumonia, for hip fractures and bowel obstructions and for exacerbations of chronic obstructive lung disease. If I made room in my mind for all of this stuff, I’m sure I would have to jettison something that is far more precious.

It is concerning, at least a bit, to be so dependent on either a computer or a printed cheat sheet to initiate treatment for patients. Physicians being trained now don’t even have a mnemonic to fall back on, and I imagine that their brains are perhaps like giant card catalogs without any of the books in the library. This, of course, completely labels me as being nearly senile, since card catalogs only exist in primitive societies and old peoples’ memories. (I can still evoke that particular wood and paper smell as I type the words “card catalog.”)

But unless physicians become familiar with techniques of advanced memory training like the ancient Greeks used for reciting epic poems, there is just too much to know in medicine. We must walk around with some of the vast amount of information that makes up our field of knowledge in order to deduce things, make connections, create solutions to complex problems, but we need to be selective. It is possible to design orders for each patient based upon disease principles and knowledge of hospital processes, recent research and individual patient characteristics.

This might be better for patients, but only if we are in top form as we write them. Patient safety advocates favor order forms, for good reason, since I and my fellow physicians can certainly not guarantee that at any given moment we will be in top form.

As I remember ABC DAVID and the days of simpler medicine, it is with the bittersweet regret that makes the past look preferable to the present regardless of whether that is in any way accurate. I would like medicine to be less complicated, and perhaps it will be if we rein in our excesses. But while patients continue to be on too many powerful medications and too many expensive and potentially hazardous tests and procedures are part of everyday practice I am grateful for preprinted order sheets and even computerized order entry when it’s not too bug infested.

I have found ways to be creative and innovative and to personalize my care for patients without excessive hindrance by protocolized treatment for high profile diseases. If the powers that be want me to remember to vaccinate and provide smoking cessation information to my patients as I am submerged in their acute, pressing and life threatening immediate needs, I thank whatever inanimate order generator that will relieve me of that burden.

Janice Boughton is a physician who blogs at Why is American health care so expensive?

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  • Steven Reznick

    Computerized order entry creates legible orders and is certainly the direction of the future. The problem is that at the moment it creates a climate of distraction and an illusion of increased communication and transparency when in fact the opposite is true in most facilities I have practiced at. If we look at the ” bittersweet” days of the past, I was taught to write out my orders and then find and review them with the nurse caring for the patient. We reviewed them one on one to make sure there was no confusion and they were accurate and they were comprehensive. In person we reviewed immediate, mid level and long term goals and discussed red flags or problems. we needed to be aware of and communicate to each other. We discussed the plan with the patient at the bedside and answered questions and left the bedside or ER after direct communication. Those orders were than handed to a clerical ward clerk who ” tubed” the orders to the pharmacy . A copy of the orders were placed on the medical chart for all to review . Today those orders are immediately questioned by the computer software drug drug interactions. Minor and trivial interactions you are well aware of and choose to ignore are thrown in your face at every keystroke and break your concentration and divert your attention from the tasks at hand. Even if the diagnosis is acute bleeding from the upper gastrointestinal tract or into the skull from a subdural hematoma, you are forced to find the right box to check on the DVT/PE ( deep vein thrombosis/ pulmonary embolus) prevention protocal to indicate why you are not giving this exsanguinating patient a blood thinner. You must complete this accurately before moving on. Invariably ordering respiratory treatments or therapy involves going to another protocal worksheet where in addition to dealing with formulary substitutions, all the drug dosage and frequency choices you may wish to use are not present. You find yourself making adjustments for the frail elderly and very young child by searching for the ” other” and ” comment ” choices most of the time.. When you finally complete the orders and insert your requests for consultation on the MD Consult Iform and order your chosen labs ( each requires over riding orders written by the examining ER staff upon arrival) you get to the medication reconciliation sheet being entered by a nurse on different software to correlate the meds taken at home with the orders now given at the hospital. A thorough and astute physician has already done this on his or her orders but you must go through it again. Then of course there is the vaccination and immunization section , which if you do not fill out immediatlely results in your elderly patient receiving their second and third pneumovax injection ( yes there can be a significant local reaction when re vaccinating) or non seasonal flu shot even though they received their influenza shot in your office during the season. Let’s not forget the unnecessary tetanus shot administered in the ED for a scrape not a puncture wound.. When you finally complete all the orders,review all the protocals that allow dietitians , pharmacists and therapists to alter your orders without even informing you or placing a note on the computerized system ( they still scribble on paper placed at the back of the hospital medical record) you have to go and find the nurse actually assigned to your patient to discuss the plan. There are no longer any secretarial staff to assist with any of the administrative or paper work because that is now the job of the doctor or nurse.
    I believe computerized order entry and hospital medical records will be advantageous when the systems are simple and user friendly. At this point they are a distraction from time in front of and with the patient and family and from communicating with nursing and allied health professionals.. They lead to communication errors in the hospital and make the hospitals dangerous places to be.

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