For this, you can use of the mnemonic AD DAVID.

Admit to (ward/department/nicu), under Dr. Surgeon
Diagnosis: confirmed or suspected (UTI w/ 2ndary dehydration)
Diet: DAT (diet as tolerated), NPO (if surg/procedures), sips only, CF (clear fluids), ff (full fluids), thickened fluids (dysphagia), advancing diet, diabetic diet (indicate calories eg. 1800kcal), cardiac diet, TPN, etc
Include amount, freq, rate if applicable.
Activity: AAT (activity as tolerated), NWB (non-weight bearing), FWB (full weight bearing), BR (bed rest), BR with BRP (bed rest w/ bathroom privileges), ambulation (up in chair tid, ambulate bid)
Vitals: VSR (vital signs routine - HR, RR, BP, O2 sat, Temp q8-12h, q shift), VS q4h (was told this is routine), special parameters (eg postural vitals, neuro vitals)
IVF, Investigations, Ins and outs
-ins & outs: surg/volume status pts
-daily weights: eg renal failure, edematous, infants
-investigations: heme (CBC + diff, PTT/INR), biochem (lytes - Na, K, Cl, HCO; urea, Cr, Ca, Mg, PO4, glu, CSF cell count, CSF protein & glucose) microbio (urine R&M/C&S, blood cultures, CSF from LP for gram stain, C&S; just rmb all the things you can culture - CSF, sputum, urine, feces, pus from wounds, blood), imaging (cxr, ct, mri, ekg, pft, spirometry), consults (sw, neuro, ID)
Drugs
-all meds pt's already on (Past)
-meds pt needs right now (present)
-anticipate what pt might need: prophylaxis, sleep, nausea & pain (future)
-10 patient P's: Problems (specific med issues), Pain (analgesia), Pus (antimicrobials), Puke (anti-emetics, prokinetics, antacids), Pee (IV fluids, diuretics, lytes), Poop (bowel routine), Pillow (sedation), PE (anticoag), Psych (DTs), Prev meds

Example
Admit to Plastic Surgery, under Dr. X
Diagnosis: Flexor tenosynovitis L D3

NPO (patient is pre-op. May be NPO @ midnight if OR not planned until following day)
AAT (activity as tolerated); Splint L hand
Vitals q8h (vitals can be more frequent if patient unstable)
IV RL @ 100cc/hr while NPO (note: maintenance IVF should be based on the 4:2:1rule)
CBC, lytes, BUN, Cr, PTT, INR qAM x2
Monitor ins and outs (for unstable patients)
Group and screen (or type and cross if ++ blood loss probable in OR – check with staff/seniors if this is needed)
EKG (if >40y pre-op)
CXR (if >50y pre-op)
Ancef 1g IV x1 on call to OR (Clindamycin 600mg IV x1 if pen-allergic)
Antibiotics for infection need to be prescribed around the clock: check with your staff/senior which you should prescribe
Gravol 25-50 mg PO/IV q6h PRN
Dressing orders (check with staff/seniors)
Patients home meds
Anaesthesia consult (if patient has other co-morbidities and high risk for surgery)

Please note that all orders should be reviewed and co-signed by a resident. Be mindful of patient’s allergies before ordering medications.