Chart checks: who is ultimately responsible for new orders?

[pinkiepieRN]

Okay, I work nights as the supervisor at a nursing home. We are having a major problem with orders being missing due to not being transcribed/faxed to pharmacy/clarification needed. I know it is our responsibility to audit the charts every night, but it is not solely night shift's fault if an order is missed. How many times have I seen an order written at 10am but still flagged to review when I come in at 11pm, seeing 2 shifts before mine? I've work days and whenever I saw a new order, I was certain to pull the carbon copy, transcribe to MAR, fax to pharmacy and "note" that I saw and faxed the order. Apparently most of the day shift nurses don't have this mentality. We're also supposed to write 2 clean, labeled order sheets at the front of the "orders" section in the chart. Again, no issues with that, but if for some reason that gets missed, days often just writes last night, first initial on the order sheet, and sends it to pharmacy, where they fax back a need for clarification - be it medical record number, DOB, room number, attending physician, allergies. I would never feel comfortable faxing an order sheet that's incomplete because it's simply lazy. It take 2 seconds to fill out all the fields.

So, the problem at hand, hardly anyone is ever taking off new orders unless it's night shift and we're doing chart checks. With 30+ charts to check every night, it's possible that something might get missed from time to time. If an order goes weeks without being taken care of (say something is d/c'ed), is it night shift's fault for missing that order the night after it was written? Shouldn't days or evenings be accountable for writing orders after that and not checking to make sure it was taken care of, just as a back up?

[BrandonLPN, LPN]

I would say primary responsibility lies with the nurse who was working the shift on which the order was written.

Night shift, of course, is always responsible to catch any orders that were missed in the previous 24 hours, since they do the 24 hour chart checks.

But the other shifts do not have the right to ignore orders with the assumption nights will do them anyway. The night check is only supposed to be a failsafe.

[Pepper The Cat, BSN, RN]

Don 't turn this into a Day Shift /night shift thing. Instead, look for patterns. Is it always a certain nurse who is missing the orders? Or is always on a certain day? Why are the orders being missed?

And yes, yes, it is everyone's responsibility. I take a minute or two at the start and end of every shift to look through my charts for orders.

[Nurse SMS, MSN, RN]

We are required to review orders that came in during the shift every hand-off for shift change. This way any missed orders are seen and implemented by the offgoing shift.

[generalRN2008]

All shifts are responsible not just nights.

[doodlebuttRN]

Sorry for the late reply.....

I experienced the same issue working in LTC; finding an order from a previous shift (or even, God forbid, yesterday). What I did was take off the order, carry over to MAR, and on the order sheet, I would write "noted: 6/17/14 at 1345 and initial. That way I am carrying out the order, but if there is an issue in the future (like the antibiotic wasn't ordered or started late, etc; I was just initialing that the order was noted at whatever time I noted it.

I might also bring it to the attention of the nurse on duty at the time the order was written: "Hey, I saw in patient X's chart that he had an order for abcd medication, but it wasn't carried out. I noted it, etc, and faxed to to pharmacy. Just wanted you to be aware; I know you had 2 admits yesterday and were super busy; just let me know if I can help with anything in the future so an order doesn't get accidentally missed." (or something to that effect; letting the nurse know without accusing and also offering assistance if needed)

If this is a regular thing, like Pepper said, always happening on a certain day, etc; a nurse consistently neglecting or forgetting to take off orders, I might notify the supervisor.

It is everyones responsibility to make sure that all orders are carried out. If a doctor comes in, I would pull the charts for his patients and double check for orders at that time (or endorse whatever could not be finished to next shift.) If I had several orders, I would only do one at a time, and complete all transcription (to MAR or TAR, or wherever else) before moving on to the next. For me, this greatly lessened the chance I would forget or miss something.

Where I worked, NOCs was not required to do chart checks; they often had more than enough to do.

Ultimately we all have to take responsibility for our own practice; but also work together, helping each other, to make sure nothing is missed.

[classicdame, MSN, EdD]

MY opinion (worth? Not much)

Nurse on duty at time order is written should be responsible for getting it into chart, to pharmacy, to lab, etc.

Night staff should CONFIRM that all orders have been transcribed and carried out

[loriangel14, RN]

What is the process for charts with new orders? Where I work the charts with new orders go on a different shelf/rack. If you see a chart on the special rack you know that there is an order to be checked.

[Savvy20RN, BSN, RN]

What is the process for charts with new orders? Where I work the charts with new orders go on a different shelf/rack. If you see a chart on the special rack you know that there is an order to be checked.

Yet, there's always that one doctor who doesn't put the chart in the right rack. Instead he/she leaves it beside the computers in the nursing station or where ever they were sitting at the time. They don't talk to the nurse before they leave the floor at night and you, the night shift nurse, who has already checked your charts for missed orders at change of shift, doesn't think to look at the chart again because you didn't see a doctor come on the floor to write new orders.

I loved finding orders written in charts by physicians during my midnight/1am chart checks. Especially by that one physician who loved to slip onto the floor at 2am to write orders for blood.

[Mn nurse 22]

I work nights and our chart checks are the "3rd" check. The nurse who takes the order is responsible to enter it into the computer and find another nurse to do the 2nd check. On nights we go through each order and make sure it was entered correctly, make sure other orders were discontinued as written, I check dosage, allergies, make sure it is in the correct section of the MAR, check the time of administration and make sure it is compatible with the patient's other meds, check start and stop dates for the medication, route, and sign off and file the order as complete. It is amazing how many little errors can be found even after 2 nurses have checked the order.