If something is called or faxed in, then the script or the order needs to be on the chart.
You are right about this.
We had, years ago, been told to destroy written prescriptions if they were called in to avoid duplication; but now I see where this has been a big mistake.....no paper trail. (not that I call in those that are actually written anymore).
I had worked critical care for so many years, it had been over 20 years since I discharged anyone and this is the only facility since then that I've worked the floor.
We keep getting lip service from administration that they are "trying" to get the docs to write scripts but still few do.
They leave us with a list of discharge meds and we have to figure out what's new and what's old, hoping that home med list is accurate!
What gets me is when people also want me to call in new prescriptions for their old home meds because they're "almost out". :angryfire
No, we don't have any clinical nurse specialists, it is a small community hospital (200 beds).