Community Acquired Pneumonia: Hospital Admission, General Inpatient (Adult)

false AND Community Acquired Pneumonia: Hospital Admission, General Inpatient (Adult) true Admission Discharge Transfer AND true Admit to hospital now Z0001 $(today) true Admitting diagnosis is pneumonia Z0002 Z0003 true Add pneumonia to problem list Z0004 Z0003 true Admit to which unit Z0005 $(admissionUnit) false Admitting service 305342007 $(admissionService) true Attending physician Z0007 $(attendingPhysician) false Resident physician Z0008 $(residentPhysician) false Code Status XOR false Main Code Status XOR false Patient is full code Z0009 false Do not intubate Z0010 false Do not resuscitate Z0011 false Additional code status instructions Z0012 $(codeStatusInstructions) false Condition XOR false Patient condition is good Z0013 Z0014 false Patient condition is fair Z0013 Z0015 false Patient condition is serious Z0013 Z0016 false Patient condition is critical Z0013 Z0017 false Patient condition Z0013 $(patientCondition) false Allergy Assessment OR false No known latex allergy Z0018 false No known drug allergies Z0019 false No known food allergy Z0020 false No known contrast media allergy Z0021 false No other known allergy Z0022 false Allergy #1 Z0023 $(allergen) false Allergy #2 Z0023 $(allergen) false Allergy #3 Z0023 $(allergen) false Allergy #4 Z0023 $(allergen) false Additional Admit, Discharge, Transfer Orders OR false Additional ADT Order #1 Z7777 $(additionalADTOrder1) false Additional ADT Order #2 Z7777 $(additionalADTOrder2) false Additional ADT Order #3 Z7777 $(additionalADTOrder3) false Additional ADT Order #4 Z7777 $(additionalADTOrder4) false Additional ADT Order #5 Z7777 $(additionalADTOrder5) true Consults OR false Infectious disease consult Z0024 false Pulmonology consult Z0025 false Respiratory therapy consult Z0026 false Social work consult Z0027 false Bedside Nicotine Program for smoking cessation 395700008 false Additional Consult Orders OR false Additional consult order #1 Z7777 $(consultOrder1) false Additional consult order #2 Z7777 $(consultOrder2) false Additional consult order #3 Z7777 $(consultOrder3) false Additional consult order #4 Z7777 $(consultOrder4) false Additional consult order #5 Z7777 $(consultOrder5) true Vital Signs Assessment OR true Vital signs per protocol Z0029 true Obtain weight Z0030 $(weightCollectionInterval) true Intake and Output Z0031 $(intakeAndOutputInterval) true Calculate severity index Z0032 false Telemetry Z0033 true Pulse oximetry, continuous at bedside Z0034 false Call if $(callAttendingCondition) Z0035 $(callAttendingCondition) false Goal: Lung sounds clear and undiminished Z0036 false Goal: No signs and symptoms of respiratory distress Z0037 false Additional Vitals/Assessment Orders OR false Additional Vitals/Assessment Orders #1 Z7777 $(additionalVitalsOrder1) false Additional Vitals/Assessment Orders #2 Z7777 $(additionalVitalsOrder2) false Additional Vitals/Assessment Orders #3 Z7777 $(additionalVitalsOrder3) false Additional Vitals/Assessment Orders #4 Z7777 $(additionalVitalsOrder4) false Additional Vitals/Assessment Orders #5 Z7777 $(additionalVitalsOrder5) true Diet OR true Encourage fluids Z0037 true Regular diet Z0038 false Weight stable at prescribed weight Z0039 false Nutrition Consult Indications OR false Diet OR false Nutrition assessment Z0040 false Nutrition support recommendations Z0041 false Education OR false Educate on Diet Modification Z0042 Z0043 false Educate on Z0042 $(educationTopic) false Nutritional Supplement Adult OR false Boost High Protien PO with meals Z0044 false Boost Plus PO with meals Z0045 false Boost with fiber PO with meals Z0046 false Carnation Instant Breakfast PO with meals Z0047 false Carnation Instant Breakfast sugar free PO with meals Z0048 false Health Shake PO with meals Z0049 false Health Shake sugar free PO with meals Z0050 false Ice Cream Plus PO with meals Z0051 false Magnacal Renal PO with meals Z0052 false Milk, double strength PO with meals Z0053 false Milkshakes PO with meals Z0054 false Poylcose PO with meals Z0055 false Renal Shake PO with meals Z0056 false Resource Fruit Beverage PO with meals Z0057 false Scandishake PO with meals Z0058 false Supershake PO with meals Z0059 false Nutrition, diets OR false General diet Z0060 false Advance to General Diet as tolerated Z0061 false Diet for age Z0062 false ADA x calorie diet Z0063 $(ADACalories) false Bland, soft diet Z0064 false Clear liquid diet Z0065 false Clear liquids, then NPO after midnight Z0066 false Full liquid diet Z0067 false High calorie diet Z0068 false High fiber diet Z0069 false High protein diet Z0070 false Low cholesterol diet Z0071 false Low sodium diet: 2g/day Z0072 2g/day false Low sodium diet: x g/day Z0072 $(sodiumGramsPerDay)g/day false No salt added diet Z0073 false Gluten-free diet Z0074 false Lactose-free diet Z0075 false Restricted calorie diet Z0076 $(caloriesPerDay) false Restricted fluid diet Z0077 $(mlPerDay) false NPO except medications Z0078 false NPO after midnight before surgery Z0079 false NPO Z0080 $(npoParameter) false Advance diet to x as tolerated Z0081 $(dietType) false Kosher diet Z0082 false Additional Diet Orders OR false Additional diet order #1 Z7777 $(additionalDietOrder1) false Additional diet order #2 Z7777 $(additionalDietOrder2) false Additional diet order #3 Z7777 $(additionalDietOrder3) false Additional diet order #4 Z7777 $(additionalDietOrder4) false Additional diet order #5 Z7777 $(additionalDietOrder5) true Activity OR false Strict bedrest Z0083 false Bedrest with bathroom privileges Z0084 false Ambulate in hallway with assistance q shift Z0085 false Activity as tolerated Z0086 false Additional Activity Orders OR false Additional activity order #1 Z7777 $(additionalActivityOrder1) false Additional activity order #2 Z7777 $(additionalActivityOrder2) false Additional activity order #3 Z7777 $(additionalActivityOrder3) false Additional activity order #4 Z7777 $(additionalActivityOrder4) false Additional activity order #5 Z7777 $(additionalActivityOrder5) true Laboratory OR false Arterial Blood Gas Z0087 true Comprehensive Metabolic Panel Z0088 false Basic Metabolic Panel Z0089 false Complete blood count with differential/platelets 9564003 false Liver Profile Z0091 false Protime and PTT Z0092 false Culture, blood, aer and anaer, x2 before antibiotics 30088009 false Culture, sputum Z0094 false Culture, Legionella, sputum or bronchoalveolar lavage Z0095 false Culture, Legionella, DFA, sputum or bronchoalveolar lavage Z0096 false PPD Z0097 false Magnesium, blood Z0098 false Phosphorus, blood Z0099 false HIV1 and HIV2 Antibodies Z0100 false Urinalysis with microanalysis, catheterized Z0101 false Urinalysis with microanalysis, clean catch Z0102 false Call if x Z7777 $(labCallCondition) false Additional Laboratory Orders OR false Additional Laboratory Order #1 Z7777 $(additionalLabOrder1) false Additional Laboratory Order #2 Z7777 $(additionalLabOrder2) false Additional Laboratory Order #3 Z7777 $(additionalLabOrder3) false Additional Laboratory Order #4 Z7777 $(additionalLabOrder4) false Additional Laboratory Order #5 Z7777 $(additionalLabOrder5) true Ancillary OR false Chest Xray, PA and Lateral-Indication: Pneumonia 399208008 Z0003 false Chest Xray A/P Portable q day-Indication: Pneumonia Z0104 Z0105 Z0003 false Additional Ancillary Orders OR false Additional ancillary order #1 $(ancillaryOrder1) $(ancillaryOrder1Frequency) $(ancillaryOrder1Indication) false Additional ancillary order #2 $(ancillaryOrder2) $(ancillaryOrder2Frequency) $(ancillaryOrder2Indication) false Additional ancillary order #3 $(ancillaryOrder3) $(ancillaryOrder3Frequency) $(ancillaryOrder3Indication) false Additional ancillary order #4 $(ancillaryOrder4) $(ancillaryOrder4Frequency) $(ancillaryOrder4Indication) false Additional ancillary order #5 $(ancillaryOrder5) $(ancillaryOrder5Frequency) $(ancillaryOrder5Indication) true Treatments OR false Oxygen via nasal cannula, keep saturation above 90% Z0106 $(nasalCanulaTargetO2Sat) false Oxygen via mask, keep saturation above 90% Z0107 $(maskTargetO2Sat) false Respiratory Therapy to Manage Oxygen Therapy Z0108 false Goal:Maintain oxygen saturation greater than x Z0109 $(O2SatGoal true Turn, cough and deep breathe per protocol Z0110 false Treatment call condition Z0111 $(treatmentCallCondition) false Thoracentesis OR false Laboratory OR false Protein: pleural fluid Z0112 false Lactate Dehydrogenase (LDH): pleural fluid Z0113 false Glucose: pleural fluid Z0114 false Gram stain: pleural fluid Z0115 false Acid fast bacilli culture with smear: pleural fluid Z0116 false Culture: pleural fluid Z0117 false Ancillary OR false Xray, chest: AP Portable-Indication: S/P Thoracentesis (immediately post procedure) Z0118 $(thoracentesisChestAPPortable) false Treatments OR false Thoracentesis tray to Floor NOW Z0120 $(NOW=now) false Additional Treatment Orders OR false Additional treatment order #1 Z7777 $(additionalTreatmentOrder1) false Additional treatment order #2 Z7777 $(additionalTreatmentOrder2) false Additional treatment order #3 Z7777 $(additionalTreatmentOrder3) false Additional treatment order #4 Z7777 $(additionalTreatmentOrder4) false Additional treatment order #5 Z7777 $(additionalTreatmentOrder5) true Education OR false Goal: Verbalizes and/or demonstrates understanding of education Z0121 false Additional Education Orders OR false Additional education order #1 Z7777 $(additionalEducationOrder1) false Additional education order #2 Z7777 $(additionalEducationOrder2) false Additional education order #3 Z7777 $(additionalEducationOrder3) false Additional education order #4 Z7777 $(additionalEducationOrder4) false Additional education order #5 Z7777 $(additionalEducationOrder5) true IV Fluids OR false IV Fluids OR false 0.9% NACL IV Bolus X mL infuse over Y Z0122 Z0123 $(naclIvBolus_mL)/$(naclIvBolusInfusionPeriod) $(naclIvBolus_mL) false 0.9% NACL IV X mL/hr Z0122 Z0123 $(naclIvRate) false D5/0.45% NACL IV X mL/hr Z0124 Z0123 $(d5_45nsIvRate) false D5/0.9% NACL IV X mL/hr Z0125 Z0123 $(d5_9nsIvRate) false Dextrose 5%/Water IV X mL/hr Z0126 Z0123 $(dextrose5WaterIvRate) false D5/0.45% NaCl w/KCL 20 mEq/L IV X mL/hr Z0127 Z0123 $(d5_45nacl_kcl20meqIvRate) false Additional IV Orders OR false Additional IV order #1 $(addIvOrdSubst1) Z0123 $(addIvOrdSubst1Rate) false Additional IV order #2 $(addIvOrdSubst2) Z0123 $(addIvOrdSubst2Rate) false Additional IV order #3 $(addIvOrdSubst3) Z0123 $(addIvOrdSubst3Rate) false Additional IV order #4 $(addIvOrdSubst4) Z0123 $(addIvOrdSubst4Rate) false Additional IV order #5 $(addIvOrdSubst5) Z0123 $(addIvOrdSubst5Rate) true Medication OR false Administer first dose of antibiotics within 4 hours of admission Z0128 false No recent antibiotic therapy XOR false Macrolid plus Beta-lactam AND false Ampicillin and sulbactam (Unasyn) 3 g IV Piggyback q6 hr C33838 false Azithromycin 500 mg IV Piggyback q day (Infuse over 1 hr) C11448 false Moxifloxacin 400 mg IV Piggyback q day C17462 false Recent antibiotic therapy excluding fluoroquinolones OR false Moxifloxacin 400 mg IV Piggyback q day C17462 false Recent antibiotic therapy including fluoroquinolones OR false Azithromycin 500 mg IV Piggyback q day (Infuse over 1 hr) C11448 false Ampicillin and sulbactam (Unasyn) 3 g IV Piggyback q6 hr C33838 false Antipyretic Agents, Adult OR false Acetaminophen 325 mg 1-2 tab PO q4-6 hr prn (Max 4 g/day) Z0135 false Acetaminophen SUPP 325 mg 1 suppository PR q4-6 hr prn (Max 4 g/day) Z0136 false Acetaminophen Suppository 650 mg 1 suppository PR q4-6 hr prn (Max 4 g/day) Z0137 false Aspirin 325 mg 1-2 tab PO q4-6 hr (Max 3.9 g/day) Z0138 false Aspirin Suppository 300 mg 1 suppository PR q4-6 hr prn (Max 3.9 g/day) Z0139 false Aspirin Suppository 600 mg 1 suppository PR q4-6 hr prn (Max 3.9 g/day) Z0140 false Ibuprofen 400 mg PO q6 hr prn (Max 2.4 g/day) Z0141 false Bronchodilator OR false Albuterol inhaled solution 0.5% mL nebulized q6 hr Mix with 0.9% NaCl Z0142 false Albuterol MDI 90 mcg/puff 1-2 puffs inhaled q6 hr Z0143 false Albuterol/ipratropium (Combivent) MDI 2 puffs inhaled q6 hr Z0144 false Albuterol/ipratropium (Duoneb) 3 mL nebulized q6 hr Z0145 false Ipratropium inhaled solution 0.02% 0.5 mg (2.5 mL) nebulized q6 hr Z0146 false Ipratropium MDI 1-2 puffs inhaled q6 hr Z0147 false Racepinephrine inhaled solution 2.25% 0.25-5 mL inhaled q4 hr prn Z0148 false Salmeterol MDI 21 mcg/puff 1-2 puffs inhaled bid Z0149 false Additional medication orders OR false Additional medication order #1 Z0150 $(addMedOrd1) false Additional medication order #2 Z0150 $(addMedOrd2) false Additional medication order #3 Z0150 $(addMedOrd3) false Additional medication order #4 Z0150 $(addMedOrd4) false Additional medication order #5 Z0150 $(addMedOrd5)