documentation question

Nurse Ratched, RN · Feb 18, 2004

Well, our NA's (who also function as receptionists and check in patients for appointments) document certain things in the chart; for instance, if an allergy/intolerance is noted, it's the responsibility of whomever becomes aware of it to document it.

My intial feeling is that the doctor should document the script, but I guess that's too much to hope for .

I guess given that the Rx is printed out on a computer, there is not danger that anything could be misinterpreted on the doc's handwriting. It's a matter of just transcribing the information from printout to chart. Errors can happen regardless of who does that. It does seem that someone with a modicum of medical training should do it, but that's just a gut reaction.

Who takes the initial script request from the patient? Is the receptionist permitted to do that?

Is the question specific just to narcs or are you wondering for all meds in this type of scenario?

darla80 · Feb 22, 2004

I guess it is about my gut reaction..

yes she documents all RX he has written in the chart , and she documents those she faxes after he has written them and hands them to the front to be faxed

Anything that needs phoned in comes to me the licensed person

To answer your question, yes the receptionsist takes the RX request from the pt..but I hear some complaints as she does not always get the requests correct .... Of course patients are at fault as well.. you know how it goes..

ring ring..."Honey can you tell the doctor I need my heart pill, or the water pill or that sugar pill." of course they may take two cardiac meds or three diabtes meds but they do not know which one they need..eg: they are taking amaryl, glucophage and maybe Actos.. which one do they think is the "sugar pill".??

After a few questions you and I would know which one they need but she does not know the questions to ask.

I tell her the pt should have thier bottles in front of them when requesting RF

Do you have phone voicemail RF request line?

thanks for your input

Joy and Smiles *

Darla

JnJTyson · Sep 13, 2004

I work for a 1 MD practice. A grand total of 4 people work here. So the RXs always cross my desk.....along with a lotta other crap..lol but as far as the print-out goes, I just copy it, and stick it in the chart. I document the heck out of pretty much everything. We have a page in front of the chart that is for all communication, if they request a refill, I call it in, chart it that I did it and who I talked to at the pharmacy. That way when they call back and say I didn't do something, I can tell them exactly what I did, and tell them to go to the OTHER pharmacy they go to..lol

Its probably much different working for a multi physician group, or an MD that is in and out of rooms like lightning. My doc takes 1 hour for a new diabetic pt...its pretty cool.

laurasc · Sep 19, 2004

I tell her the pt should have thier bottles in front of them when requesting RF
Do you have phone voicemail RF request line?
thanks for your input
Joy and Smiles *
Darla

Med refills....the bane of my existance. I work in a clinic with 7 docs and a patient population of about 15,000. Of the 7 docs, 2 use the computerized rx program and the rest do not. One is notorious for not documenting his meds. Our clinic policy is that we the nurses do not automatically refill meds but the patient must see the doc for that. We can, however, phone into the pharmacy enough meds to cover until the patient comes in to see the doc.

Problem # 1 is the sheer numbers of refill requests per day.

Problem # 2 is the fact that a lot of the patients requesting the refills don't know what the meds are. They want the water pill or worse, the little green, triangle shaped pill that they take once a day.

Problem # 3 is the doc that doesn't document his meds. Nuff said.... :uhoh3:

Problem # 4 is trying to get the patient to understand that they must see the doc to renew their meds and deal with their anger. I have been an office nurse for ever 12 years and I have never been this badly treated by patients.

virmm1, LPN · Oct 13, 2004

The office I worked in has the Logician computer program. When Docs did rxes on the computer the record was there so it didn't need to be documented a second time. The front desk has a notebook where the rxes are signed for by the pts when they are picked up.

We did have a pharmacy line at one time but it took a nurse all day to get the requests off of it. Refills are now done by fax only.The docs have wall bins that their refill requests are put in and its up to that docs nurse to see that the refills were done. It got to where we had a same day turn around for the most part.

Of course we still got calls where the pt called their refill in at 9A and it wasn't done by 10A.

Logician was also handy because the entire healthcare system had it. If a pt went to another office,tht visit would be in Logician . We had one pt that was famous for calling one of our docs on his on call day demanding Xanax refills. Well, it just so happened tht she called one evening not long after we got the program up and running. As it turned out,1 our doc wasn't her PCP and 2 she had been to see her doc that very AM. Our office lead who was working took the call and asked her why she didn't get it from her doc when she saw him that am. You could've heard a pin drop. She ws promply sent a letter telling her that she needed to get her meds from her doc.

Also with the program its easy to reconize drug seekers.

Our head nurse at the time sent letters to the pharmacys re: faxing Rx refills.

Once this was in place, the pts were told to call their pharmacy and they will contact us. The pts were also told that it ws a 24hr turnaround . Of course there were still calls from pts where they ran out of their meds. We had a list of meds with guide lines that we as nurses were authorized to refill by the docs. HTN, thyroid, stomach med, the serious drugs still needed the doc to ok. Those rxes we had to document. We could also fax refills thru Logician so it was documented as it was done.

Our head nurse worried the docs to death to get them to give more that 1 refill on some of those meds. We had pts calling monthly for B/P med refills.

darla80 · Oct 20, 2004

Logicain sound interesting

Do you use an Electronic medical record for all entries?

So is the Logician program linked to the chart?

Darla

virmm1, LPN · Oct 20, 2004

Yes. Logician becomes the chart. There will still be the paper chart, but those were used mainly for previous information prior to Logician. Each pt has a chart in Logician. Once their names are in the system, pt information has to be Preloaded, (Entered by the nurses) allergies, dxes, meds, immunizations, Drs name. When pt comes for a visit, everything is entered into Logician instead of writing on the nurses notes in a paper chart. Whats nice also is that once the doc is finished w/ the visit, and hs put his visit info in the computer, the new rxes and refills that is done at the time of visit will be in there. He/she no longer has to dictate. What else is nice about it is that every user in the system has flags, like e-mail so that phone messages from pts can be flagged to the nurse, cuts down on nurse pages when pts call. Unless something is important and needs immediate attention. Of course there will always be those stupid pt questions. The flags also have a status icon, URGENT,IMPORTANT, and then everything else. So the nurse knows which ones to do first, but they are looked at thorugh out the day. The flags can either be forwarded to the doc if needed. We found that is ws quicker, depending on the docs preference, to print the flags out and go over them in person, that way the answer could be written on the message The flags can also be converted to a chart document with the reply to the message. Another nice thing about Logician, is that the docs can have it in put on their home pc. Great for on call when they're not familiar w/ a pt.

BUT, when Logician is down you have nothing.

It will also work wonders for your typing skills. I can actually type without looking at the keys now. Couldn't do tht before.

Ruth

darla80 · Oct 23, 2004

I think I will tlak ot my Doc about this ..

Are you in a large office?

I am in a small IM office ..one doc . one nurse

but we use the computer alot..computers in each exam rooms, nurses stations etc and terminals all over the office

we do computer messaging..has also helpd my typing skills but I still make to many spelling errors

Thanks for the info

have a great Day!!