Orders.

Specialties Geriatric

Published

So today i come in from a weekend of not working, and the 7-3 nurse tells me that an order i transcribed last week was dc'd.

I go to the MAR and it is clearly dc'd by a nurse that works only weekends.

She dc'd it because she "couldn't find the order."

The order was clearly written on a lab result sheet signed by the NP clearly in the chart.

plus the med is in the cart.

The med wouldn't have been sent from pharm w out a signed order.

Where is common sense sometimes??? Read??? Please???? Now this man has been w out his med.

sorry for the rant but i hate stupid stuff like this.

Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
Where is common sense sometimes??? Read??? Please????
Too many people take the path of least resistance these days. By taking the easy way out, common sense seems to go out the back door with the rest of the garbage.
Specializes in LTC.

Most facilities that I've worked for require all orders to be written on a Telephone/Treatment Order so that it may be sent to the PCP for a signature. Writing orders on lab sheets alone is not an acceptable order in my facility. However, the weekend nurse could have/should have found it by reading where it was documented in NN and checked lab results to verify that an order was received.

Specializes in LTC.

To clarify, even if the MD signs the lab it's still facility policy that T.O.'s be filled out. Extra charting, I know, but policy nonetheless.

Specializes in LTC.

I would not have dc'd the order. She should have written out a proper order instead of dc'ing it. If that's what the prescriber wrote on the lab sheet that's the order they want. We would still need to write the order out on a telephone order sheet.

Specializes in LTC, Memory loss, PDN.

an order was discontinued, without getting an order to do so, as in clarification, because the original order

couldn't be found ??? :no:

EHR will take care of that, until then, have that person fill out the med error form

an order was discontinued, without getting an order to do so, as in clarification, because the original order

couldn't be found ??? :no:

EHR will take care of that, until then, have that person fill out the med error form

Exactly!! If an order couldn't be found...it would be an order error!!!

Specializes in LTC,Hospice/palliative care,acute care.

This would be a med error/order entry error on your part(and the NP if she/he wrote that order) where I work. However the nurse on duty should have done some homework and reported this to the supervisor and at least read through the nurse's notes to try to track down what happened. Maybe someone could have made a call to you since you actually wrote the order on the MAR. Where I work I would have had to enter a verbal order,never would we just leave it on a lab report.

Who wrote the order on the lab slip? That's not an order-we do that just to alert the physician the lab was addressed when he comes in to do rounds and signs off on it. You sound more upset at the actions of the co-worker for d/c ing your entry on the MAR then in taking responsibility for your own actions.

If I couldn't find an order, I would call whoever (NP, MD) was most responsible for that patient and clarify, or if it wasn't too late and the facility permitted it, I would call the nurse who put the order in and ask them the details.

Communication and clarification are your friends!!!

Gotta have a telephone order for everything. Lazy nursing on part of the weekend nurse for not having investigated but correct in that no order was written.

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