How many places do you document an order?

  1. I'm just sort of venting here and curious as to if anyone can add to this list.
    Okay suppose it is an order for routine pain med:

    So there's your initial assessment
    A call to the doc
    The T.O.
    MAR with notation of pain med given and effectiveness on pain scale
    Pain Scale in chart
    Pharm Fax
    Nurses Note when med given and follow up note
    Pain Assessment
    Care Plan
    Call to Family to notify of new order
    If you have a change of condition form
    E Kit for med, counting the E kit documenting med taken
    Shift to Shift Report
    Then you are thinking "now I know I forgot to document it somewhere?" Oh yea the new MAR for the upcoming month!

    If it's an antibiotic there's even another form!

    So how many places do you have to chart a new order?
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  2. 7 Comments

  3. by   CoffeeRTC
    Hey...sounds like you're in LTC Same here!
  4. by   flashpoint
    Sounds about right to me...LOL. Do any of the computerized systems automatically put new orders on the MAR, care plan, pain scale, pharmacy note, etc?
  5. by   NRSKarenRN
    Home care includes all of the above except family notification.
    In PA, I'm able to call the RX into the pharmacy instead of faxing an order if doctor reluctant to call. So a followup call to patient to see if med obtained added to list --- pays to be on first name basis with pharmacists who still provide delivery service.
  6. by   NRSKarenRN
    Quote from cotjockey
    Do any of the computerized systems automatically put new orders on the MAR, care plan, pain scale, pharmacy note, etc?
    In your sweet dreams!
  7. by   nursegoodguy
    Anyplace I worked that had a computer system meant you had to do all your hard copies plus extra stuff on the computer!
  8. by   purplemania
    I am in a n acute care facility. We have almost as many steps, but not all. There is no calling the family. What a pain!
  9. by   bellcollector
    Where I work we have a pretty cool computer program. We call MD for order, notify family, then we fill out a TO form on computer that has boxes to check even place to check that family notified and all. We fill out the form on computer hit print and it shoots out a paper with all these peel off stickers 1 for the MAR, an IPN(nurses note), pharm order sticker to put on med fax sheet, and then another one that tells you which care plans are appropriate. Then we have a file of care plans and we just get out the ones that came up on the sheet. That is it. I think it is pretty amazing. Sure make my life easier.

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