Getting it on the MAR: How hard is that?

[nursemouse]

Hi! After being "silent" for awhile while swamped with a new job, I'm finally back and using this wonderful forum and the great brains on it. Thank you!!!

Now for my question: for some reason, (actually, probably a lot of reasons...) we're having trouble with the basic process of getting physician medication orders accurately onto our MARS. Basic processshould be simple: doc writes order, secretary or nurse faxes to pharmacy, order goes on MAR, nurse checks order against original, 24 hour check catches any errors. But in our case, it isn't working as well as we'd like.

How does your facility get MD orders to pharmacy and to nursing, and on the records. Do you have direct MD order entry? An organized system? Docs trained to bring the chart to the nurse or secretary, or put it in a certain place? Nurses who do a GREAT chart check? Please share your brilliance. Thanks! Nursemouse (Jeannie)

[Katnip, RN]

Each of our order sheets has space for three separate sets of orders. Doc writes orders or phones it in (we dont take verbals. If the doc can stand there and tell me, he or she can write it down.) Behind each original are three sheets for copies.

We have flags on our charts--green for new orders, red for stat. Charts go on secretary's desk or chart rack, secretary or nurse transcribes orders onto MAR, a copy is either faxed to pharmacy or put in a box to be picked up by pharm tech. If it's stat we walk it around the corner to pharmacy.

When it's done, nurse double checks that orders got to MAR and signs off on the order. Flag isn't taken down until the nurse checks ALL the orders and signs them off.

[ohbet]

Your orders arent being transcribed to the Mar because of the human factor,human error.No matter what process you have in place,people will screw up.

[nursemouse]

A quick thanks for all of the assistance you provided. You helped make a difference for me and my colleagues. Your help was SO appreciated! Nursemouse (Jeannie):kiss

[live4today, RN]

Originally posted by nursemouse

................................................... Docs trained to bring the chart to the nurse or secretary, or put it in a certain place?..............Nursemouse (Jeannie)

Now THAT would be something to capture on video! :roll :chuckle

[P_RN, ADN, RN]

Our secretaries were THE BEST with "that look" and once a doc didn't do as they should, the secretary would inform them of such........I can only think of maybe 5 times in 20+ years that a doc got away with it.

Charge nurses were also very quick with the expression, "your order needs to go to the secretary or it won't be carried out if they can't see the chart".....(where you threw it, where you repaced it in the carousel with an order, etc........

As the twig (intern) is bent so goes the tree (attending).

[etmx5313]

Working in a nursing home, our system is a little more complicated--here's how it usually goes.

1. Nurse working answers phone--because the "lady at the front desk--who has nothing to do with any orders-just answers phone---is on break, lunch, gone, whatever.

2. Nurse receives order and writes it on piece of scratch paper, because she has grabbed phone in dining room away from desk.

3. Nurse is called stat to resident room because resident has fallen and is c/o hip pain.

4. Nurse assesses injured resident and takes vitals.

5. Nurse calls M.D. for order to transport injured res. to E.R. for evaluation of hip pain/ext. rotation/shortening of leg. and awaits return call

6. Nurse receives order to transport res. to E.R.

7. Nurse completes 2 pages of paperwork to send with res. to E.R.

8. Nurse notifies family and E.R. of res. transfer.

9. Nurse speaks with family member of resident in Rm. # --- about why res. cannot have his pain meds at bedside and take, "whenever he needs them."

10. Nurse makes note of this conversation on calendar to call M.D. in morning about above.

11. Nurse receives phone call with report from hospital about new admission being sent over. (This is surprising news to nurse, as she has heard nothing about this new resident.) Unfortunately, this report does not contain any actual orders for new admit. These will be received upon arrival of new admit and will undoubtedly contain some, "challenging" orders, such as: Lortab 1 p.o. q. 4 hrs. ( strength please.) TED hose. (on for one hour, two hours, three days, off at night, on in a.m., etc.?) Extension block. ( once daily, twice daily, three times daily, or just freakin continuous?) Albuterol nebulizer p.r.n. ( strength, how often, etc. etc.) ............you get the picture.

12. Nurse receives call in for next shift immediately after hanging up phone.

13. Nurse must search for replacement for above call in.

14. Nurse reaches in pocket for pen and..............surprise! there is that pesky order that she received 3 hours ago.

15. After writing up T.O., adding to CPO, entering order in computer, calling or faxing pharmacy, (hopefully this is during 9-5, because otherwise nurse must page pharmacist on call and await call back.), then nurse must hunt down medication cart with medication aide for MAR to write new order on.

16. Unfortunately, on the homestretch to the med book and MAR, family member sees nurse and inquires about resident, "funny breathing," which upon quick inspection is actually, "Kussmaul" respirations because resident's blood sugar upon checking is 670. Family member then realizes in retrospect that, "Maybe we shoulden't of given him that Krispy Kreme doughnut." WOW-hindsight IS 20/20!!

17. Okay, you get the picture on why our orders sometimes don't make it to the MAR!...................and by the way--we would kill for a HUC or a unit secretary--just dosen't happen where I work. On weekends, the nurses answer the phone 24/7, cuz apparently dietary, activities, physical therapy, etc. is unable to figure out what that incessant ringing is!!

[1RNLadybug]

I work at a small hospital/rehab facility. We still use Kardex's! Orders are few, yet STILL at times don't make it to mar and takes days to realize it.

It goes back to the nurse that received the patient & missed the order. We had a patient come in with "obstipation" and was to get reglan IV q6h, I found it 2 days later.

We sometimes get too busy to start at the beginning of the chart & verify with kardex & MAR.

In fact, I found out that at this small facility, if a med isn't charted on mar and signed off correctly, the facility wont get paid for the med...same thing with procedures. For instance, I was so excited to get to leave because they had too many nurses, I forgot to sign off a whole page of MAR's, even though I came back in & signed them, it was still an error. Also, someone had billed a $7,000 procedure incorrectly and now the facility has to eat the cost because they can't bill for it once the 3 day limit has passed.

I've been a nurse for 8 years and usually if someone forgets to sign off the med, the oncoming nurse will call, verify it was given, and let them sign it the next day, without concern.

I learned something yesterday...take your time and make sure you document completely. We all make mistakes, the thing is to learn from them.

Happy nursing!

linda

[pwp1289]

we are now piloting palm pilots for med passes--not very good for big med passes (like 10am) but great for prns and ivs and piggybacks. just take med (already bar coded by pharmacy) to bed side-scan pts id -scan med and its charted !!!!!!!! we no longer have to take entire med cart up and down hallways--especially helpful during night tour. everything and i mean everthing must be done by computer--it is an extreme situation when we take verbals--each unit and md offices have at least 6-10 computers so 1 is always available. Wasn't too computer savvy when we started but now I thoroughly enjoy having them at work------just don't ask ask what happens when computers "go down"

[zambezi, BSN, RN]

We used to have the three copy paper, one copy would stay in chart, one would go to pharmacy(tubed). Apparently that system had issues at my hosptial, it would get lost in the tubes, pharmacy couldn't read the copies, etc. Now, we get or write order, fax it to pharmacy-if stat place priority sticker on it (and I call them as well), stamp it with a special stamper that has date/time and a place to sign, and put it in chart. RN that faxes it writes order on mar, if it is a d/c order, same system but RN "pinks" it off mar. New mars are sent at 200 am and are supposed to be checked against origingal order (though some check it against previous mars). Our post open hearts have standard orders and we have mars preprinted, we just double check when patient returns from surgery for any deleted or added meds. We can override a fair ammount in our omnicell units if it is not a special order and then just put a note in the omnicell "brand new order" or emergency med or whatever the case is. We also have mar reconciliation forms that we utilize (though sometimes i question if anyone looks at them) We use this to delete meds off the mar, a copy of the order must also be sent with it. It is usually used if a med was either forgotten to be taken off, times are wrong, med was not added to mar despite being faxed. We are going though this whole pharmacy/rn system change to streamline the process, some days it works better than others. We also have a "missing med tech" that you can call if you can't find a medication, therefore not having to bother the pharmacist who is trying to transcribe all of these orders.

[NeuroICURN]

The way we do it is this.

Our charts are usually at the bedside. Our ICU is open and long, so it's a pain to keep at nurse's station.

Doc writes order. Most will let you know they wrote order since they're usually asking you what you need anyway. But every once in a while, one will sneak in and write one when you're busy with other pt., so I try to check my chart pretty frequently.

Anyway, our pharmacy is right in our unit!!! And can I just say that "GAWD, I LOVE THAT!!!!". So, we just drop the carbon copy of the order off in their box.

Now, we use Emtek (computerized charting, MAR, etc) so either we or the secretary can enter meds into the computer. If the secretary puts it in, then she marks the med as being "not checked by RN" and then when the RN checks the order, she checks it in the computer also.

Now, as for checking charts...we check our charts EVERY shift!!! Quite frankly, I don't think it should be done any other way!! Although I realize this isn't always realistic outside the ICU where you have 6 or more patients.

As for orders being wrong on the MAR....well, let's face it, ultimately it is OUR responsibility. So if you are uncomfortable with the system you have in place, then I would suggest checking all your meds at the beginning of your shift, before you give them!

[mattsmom81]

My biggest frustration is pharmacy not keeping up...we fax the med orders but they deny getting the faxes even after 2-3 faxes and followup calls. Very frustrating. We have had this problem for a loooong time and I suspect the pharmacy techs are chucking the faxes. They claimed for awhile it was the machine, but they're all new...and its still happening.

We are supposed to be computerized and PYXIS/ Accudose for most drugs, but pharmacy slows us down considerably. Now we will go to EMAR which will be even more time consuming.

Sure wish my docs would train...too many rack new orders...I have to frequently chase them and the charts down to see what they're writing.