Chart Checks

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    Just wondering if other places have to do as much checking on orders as the rural hospital I work at. Every time any order is written, the nurse notes it, then another nurse has to check over it and co-note it, then the night nurses have to go through all the orders making sure everything is done properly and note that the chart was checked. I can understand the reasons for doing all this, but just wondered if anywhere else they had to do all this.
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  4. 0
    I'm at a rural place too, we don't do that. The orders are noted once, by the pt's nurse.
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    Quote from BowlerRN
    Just wondering if other places have to do as much checking on orders as the rural hospital I work at. Every time any order is written, the nurse notes it, then another nurse has to check over it and co-note it, then the night nurses have to go through all the orders making sure everything is done properly and note that the chart was checked. I can understand the reasons for doing all this, but just wondered if anywhere else they had to do all this.
    In our urban hospital, a nurse takes care of any order that comes along and sees that it's carried out. Doesn't need anyone to look over his/her shoulder. But each shift is also responsible for doing a chart check.
  6. 0
    I work in long term care, and the night shift does a 24 hour check of each chatrs doctor orders to ensure all orders are transcribed properly and nothing was missed.
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    Here each order has to be noted by the RN/LPN (and the secretary who put in the orders). Any radiology/labs/diet/equipment orders are put in by the secretary, and she has to write the order number beside it(it pops up in teh computer when she enters it, as a confirmation). Nursing has to do the same for meds. We verify the meds are correct in the computer, then write the confirmation number beside it on the chart. Makes sure each individual one was addressed. HTen each nurse does a chart check each shift.
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    At my hospital we have a 24 hour check that night shift does. And of course if a unit secretary takes off an order, a nurse will look at it and check it. So everything is double checked that way. I think any more would be needless.
  9. 0
    I am a SPCA & US. I do most of my US work on night shift on an observation unit, where I basically just do admission orders. Upon getting the admission papers from the ED, I: scan the orders to pharmacy (so meds are being taken care of), stamp the orders as scanned, next I enter all orders into the computer, print out a list of everything I ordered, I add all orders to the Kardex info, print out a copy of the Kardex for my RN to check, add all meds to the MAR sheets, sign off my orders with my name, title, date, & time, and finally I flag the orders for the RN to check over, let me know if something needs to be changed, and then for him/her to sign off on the orders too.

    ETA: At least 2 names have to be signed on all the orders, along with them being scanned in. I believe the night shift nurses on my unit generally go back and check to make sure all orders were signed off and done for the day. However I'm on an observation unit, so most patients aren't there for more than a day and the orders aren't piled up like a regular inpatient's orders.


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