Noting orders

  1. On the unit where I work, it's the charge nurses job to note all orders. This includes making sure orders are in the computer and on the Kardes. THIS DOES NOT INCLUDE checking the MAR. The primary nurse is responsible for getting MAR changes done, but does not have to sign the order. Same plan goes with the 24hr chart checks, the charge does the computer and Kardex, the nurse does the MAR.

    I say this goes against the Nurse Practice Act (Tx). If you sign off an order, you are responsible for the computer orders, kardex, AND MAR. Whose to say the primary nurse saw the medication order, or to despite you, or due to laziness, just didn't follow through. I say whoever signed off the order is responsible.

    My nurse manager disagrees with this, saying that if everybody checks the MAR at the begging of thier shift with the Kardex, we won't have a problem. Problem is nobody checks the MAR with the Kardex.

    I would like to hear thoughts and comments on this. Am I too anal retentive and compulsive?

    Thanks
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  2. 9 Comments

  3. by   KatWright
    What kind of facility do you work in?
    I did this kind of nursing in 1974 !!! and not since then.
    I do believe that you are right about the nurse practice act. Why do you do it this way.
    When I am looking at a problem I ask myself these questions:
    What is the problem?
    Why is it a problem?
    Who decided to do it this way?
    Is it the right decision?
    Is there another way?

    Then I list the pro's and con's. That is the hardest part because you have to be brutally honest when doing the pro's and con's. Sometimes I found that I wasn't right, that the old way was OK, but quite often I found that I WAS right.
    Also, people listen more when you get the emotion out of it and the facts to back you up.
    Do a literature search (have the library help) Find articles and reaserch studies that show how to do it better, more efficiently, more cost effective.
    Again, sometimes this may show that you are right or wrong.
    Would each nurse have fewer patients if this charge nurse took patients and each nurse did their own orders?
    Also, why are you still using cardexes and hand written MARS, no computer? Maybe it is time for that too.
    Good luck
    Kat
  4. by   nurs4kids
    We still do handwritten Kardex and MAR's, too. Charge nurse takes all the orders off. Our rule is the person who signs the order off is responsible BUT the ultimate responsibility falls to the nurse assigned to the patient. The assigned nurse is responsible for checking the CHART to verify the MAR and Kardex is accurate (we don't routinely do this d/t time constraints, but we do scan our charts at the beginning of shift). If you're not talking about long term care, the best thing to do IS to go by your chart. If you're talking long term, it's a bit too much to follow.
  5. by   nilepoc
    Yikes, as a charge nurse, I would go insane if this were the way my facility worked. I bet there are over 100 orders a shift on my unit. I cannot imagine having to check them all. I usually operate on a philosophy that all nurses have licenses, and are responsible for their own stuff.

    Craig
  6. by   P_RN
    With over 100 orders do you think the bedside nurses have time to keep running back and forth to the charts?

    Our charge nurses checked ALL new orders, verified they were entered into the computer and that they were transcribed on the preprinted MAR correctly by the secretary. We gave up the Kardex over 10 years ago.

    The new orders for treatments and ADL's were handwritten on the computer printout for that shift. When the next shift came on they would have been printed out on their charting sheet.

    The new daily orders were handwritten on the MAR, then the next day's would be checked against the old one by the night nurse to verify it had been printed correctly.

    The charge nurse had a form posted to pass all orders on to the bedside nurses/team leaders. It was their responsibility to carry out the order. If there were a question the bedside nurse would go to the chart. We had no problem with this system.

    I would NEVER sign that I had checked orders if I were not allowed to check the MAR! Goodness knows what could go wrong there.
  7. by   swacht
    Thanks for all the input.

    I work on a step down ICU unit. We do use computers for everything except the MAR. (Thats coming soon). Despite all the computer assistants, we still have paper copies of everything. Thats another project to tackle.

    My goal, as a new person to this unit with >10 yrs exp is to have each nurse to do thier own orders, since each nurse only has 3-4 pts each.

    I appreciate the input!
    Sharon
  8. by   nur20
    I agree 100%. Whomever checks and signs off the orders should be responsible for all entries from start to finish. This sounds like an accident waiting to happen!!!!!
  9. by   Genista
    I agree that whoever signs off orders is 100% responsible for making sure they are all ordered/on Kardex/transcribed to MAR, and faxed to pharmacy. We have a real problem with noting of voluminous orders on our renal/tele floor. Many pts have at least 2-3 docs (each writing orders). The nephrologists routinely write 1-2 pgs of orders per pt. The "charge" nurse tries to do order entry & help w/ noting orders, but we ask our staff nurses to try & note their own orders whenever possible, and even note other nurses orders if they have time to help out. Our NOC nurses do 24 hr chart checks.

    Our biggest problem w/ noting orders is that several nurses are LAZY and negligent and do not follow the procedure. Many will "sign off" a chart, but do not check the KARDEX or MAR, etc. and that is very wrong & dangerous. We are going to be having a unit meeting soon & this topic will be at the top of the list. What we really need is another person at the desk to help w/ orders, and we are working on that, too.
  10. by   WashYaHands
    In the facility where I work the policy is that 2 nurses sign the order. The primary nurse is responsible for the initial sign off which includes updating the kardex and MAR, carrying out the order and notifiying any other dept of the change. After the order is initially signed off, we have a color coded wheel on the chart that we change to "yellow" indicating that another nurse needs to review the order, make sure everything is annotated, etc. and co-sign. This may seem like double duty, but our policy does not require 12 or 24 hour chart checks so we use this system.

    With staffing shortages, the policy has been amended to allow the unit clerk to initially take off the orders or co-sign. The charge nurse also takes off orders if he/she has time or if the staff nurses are swamped and can't get to it right away. This system probably wouldn't work in a larger hospital, but my facility is a 50 bed hospital and we only have 4 or 5 doctors writing orders.

    Linda
  11. by   Doey
    Where I work the secretaries take off the orders, putting labs etc into the computer, calling MD's offices for referrals/consults and any notifying any other departments as needed. They write in the meds on the MAR (computerized ones coming soon), and rx's etc in the kardex checking off each order in red. They then sign the order sheet in green with the date, time, their name and title.
    The primary nurse, not the charge nurse, then checks all the orders, writes in the correct times for medication administration on the MAR and in red signs the order sheet as noted with the date, time and their name.
    I too agree that whoever signs off the orders is responsible for following through. As for 24hr chart checks, each nurse is responsible for doing their own including the MAR.

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