Change dosing time - electronic charting

Nurses General Nursing

Published

If a doc enters an order for a med to be given qpm, it "populates" the e-mar at 2200. Recently I had a doctor come by the desk and ask me to give said med at dinner (to avoid nausea), which was at about 1800.

How would most people handle the documentation of this? Would you ask the doc to change the order, reschedule it in the computer yourself, or ask the night nurse to sign it off for you later? Or some other way? Without making any changes, the earliest I could sign it off myself would have been 2030 (90 minutes ahead of the scheduled time) and that would occur after my shift ended.

trixie

1 Article; 49 Posts

I would ask pharmacy to change the time, would go ahead and give at 1800 as ordered (our system just gives a warning message). I never ask others to document for me.

AnnaN5

429 Posts

Specializes in AGNP.

I would just call down to pharmacy and ask them to permanently change the dosage time. We have to do that sometimes for patients who have a med ordered daily that our pharmacy automatically times for the am but they take it in the pm at home.

mjjlRN

28 Posts

I would either call the Pharmacy and ask them to reschedule the dose, or I would ask the MD to write a clarification order, with the dose due at 1800 instead of qhs. I would NEVER give the dose and then ask the next shift to sign it off for me, nor would I sign off a med given by the previous shift.

wooh, BSN, RN

1 Article; 4,383 Posts

Ask pharm to reschedule. If I thought it would be a problem, or it turns out to be a problem, write it as a verbal order.

RNKPCE

1,170 Posts

I think it really depends on your institutions practice. Where I work pharmacy would think you were nuts to ask them to do it. The responsibility falls on the doctor or the nurse at my hospital. If I would put it in I would do it as a verbal order if the doctor told me to do it verbally and change time. We also have option to reschedule doses if patient off the unit for tests. It also depends on what kind of e-charting system you have.

jlb_rn

31 Posts

is the dose going to be given with meals going forward or was this a one time thing? if you have the ability, change the time so that it occurs at meal time for your dose and all doses going forward. our system enables the nurse to change med times - we "reschedule" and select the reason why from a drop down box and add comments if needed. if you are unable to change the time, either have the doctor or pharmacy re-time it (or whoever has the ability with your system).

never have someone chart a med for you or vice versa. :)

blondy2061h, MSN, RN

1 Article; 4,094 Posts

Specializes in Oncology.

We can change admin times our self unless the prescriber "locks" it.

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