My issue is with physicians entering orders into the computer AND on the charts. With one eye glued to the computer so nothing is missed and the other glued to the chart so nothing is missed, who's gonna watch the patients???? Last week, a physician wrote an order on a chart at 1710 and placed the chart WHEREVER, but not in the rack for new orders.
Needless to say that when I got report from the day nurse, she was unaware of those orders because she couldn't find the chart. The patient situation was different from what was on the chart because the physician had come in, removed some things from the patient, and had not told the nurse. We finally located the chart around 2045. So I checked the ENTIRE chart for other orders to be carried out. (Patient has orders for discharge the next day. Ok, no problem. At least we know the deal now. So I proceeded to do the 2100 med pass. When I finally got a chance to do the official chart check, it was 0130 because of admissions, two very needy patients in a group of six, and I made number 7 who had to go to the darn restroom, too, but hadn't had a chance to go since BEFORE I clocked in at 1830.
Anyway, during the chart checks, the SAME doctor went elsewhere in the hospital, pulled up that SAME patient's electronic record, and entered NPO after midnight orders for surgery in early AM. WHAT!??!?! REALLY?!??!!! What happened to the discharge orders?????? That is a very important change and a huge leap in the plan of care which should have at least deserved a phone call, you think????
We have a list of physicians who are 'resistant' to computer entry, so we know that when we see those physicians or their representatives, to go check the chart. But these others are like loose cannons randomly firing off orders verbally, handwritten in the chart, and when they tire themselves out, they roll over and enter them in the computer. There is no end and LOTS of orders are being missed because of this. At some point, we as nurses have to stop checking for orders and actually go DO the work ordered. They don't seem to understand THAT little detail!!!!