New to Clinic setting, LPN here of 5 years hospital/ltc.
What are the legal guidelines for prescriptions in a clinic setting being called in and documentation of such?
Do you still use "TORB" to document, etc.
As of now, I am the first and only nurse for this clinic and until now the secretaries have been calling all prescriptions in including some narcotics (ambien, etc - sleep clinic). They obviously aren't "TORB" or "VO" documenting since they aren't nurses, and some of the time they use post it type notes where the doctor has scribbled a prescription and putting that on the chart as documentation. I am trying to establish guidelines but it's hard since I have never worked in a clinic and I am the first nurse and only nurse in this one. Thanks.
Aug 1, '11
Whoa...that would not fly here, I'm assuming this is a small clinic? We use electronic charting and only nurses or MAs call in prescriptions. we can send them electronically or call them in and then the physician has to sign the emr in a timely manner, and there has to be documentation as to why the med is sent. (We actually had a nurse fired for that)
I work in a pulm/ sleep clinic and the nurses call in ambien, lunesta, etc. And the provider signs the document
Maybe it varies by state, but certain controlled meds must be printed, signed and given to the patient.
I don't know, but maybe you could check with your BON.
Hope this helps.