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Do you write medication orders?

Posted

Do you write out RBVO for medications on the field (Marcaine, Heparin, Surgicel, etc) in the patients chart? I was wondering if anyone's institution has a different policy (ie: standing orders of meds for specific procedures) than writing out verbal orders in the chart.

Rose_Queen, BSN, MSN, RN

Specializes in OR, education. Has 16 years experience.

We use our preference cards as orders, since one is printed for every case with each patient's name/DOB/etc on them. However, we just went to an EMR hospital wide that we will begin using next year and supposedly we will be having order sets- each specialty/procedure will have a preprinted order sheet that we can check off with local, other meds, foley, SCDs, etc. as a verbal order and have the surgeon sign when he writes his op note.

Mr. & Mrs. RN

Specializes in OR. Has 9 years experience.

When we print out our surgical record with medications documented, an extra page prints out for the Dr.'s to sign at a later time. Pref cards are used as standing orders.

Our institution won't allow standing order sets, so it all has to be put in individually. We go off of our preference cards, or whatever the physician asks for. We can't chart verbal order though, it has to be put in as "perioperative order". In some services the residents/PAs are awesome and put in most of the orders but most of the time it falls on us.

shodobe

Specializes in O.R., ED, M/S.

Nope, can't think of any real, logical reason to except those who are extremely picky, picky about the most minute irrelevant detail. Just my opinion, waste of your vaulable time.

CaliLvr000, BSN, RN

Specializes in Operating Room. Has 7 years experience.

We do not, and I wonder how we do all of those things without orders, but as of now we do not.

daVinciNurse

Specializes in OR. Has 13 years experience.

We do not, and I wonder how we do all of those things without orders, but as of now we do not.

I was once told it is OK to not have a written order for it all because the ordering physician is standing in the same physical space and its under surgeon's direct supervision. Not sure what/where this info came from or how old it is. Also not sure how true that is, and keep in mind facility policy can over ride it..... I've worked in facilities where I had to write out orders for intraop xrays and other facilities say its not necessary--rumor had it that by the state regs, xray techs could not take "verbal" orders so nurses had to write/read back the order and give it to the xray tech---what a joke....the xrays were usually done by the time nurses ever got around to writing the order.

BridgetJones

Specializes in LTAC, OR. Has 3 years experience.

Not sure why you would need to when the physician is the one who is actually administering the medication to the patient. We just chart what meds we dispensed to the field. X-ray and specimen orders we put in the computer as verbal orders.