Getting new orders

Specialties LTAC

Published

My question is about how to go about new orders. I just started my first nursing job in a LTC facility. I graduated a couple months ago. I feel like the paperwork is the hardest part in these first few days! We didn't do any orders or dealing with doctors in nursing school. So when do we need a script from the doctor? When we fax the doctor about needing a specific med/upping a dose and him faxing back with an "ok" do we need a script or just write a telephone order and fax that to pharmacy? When we have a script do we also need to write up a telephone order to send a copy to pharmacy and medical records? Thank you in advance for any help or advice! :)

Specializes in LTC, Management, MDS Nurse, Rehab.

Where are you working... Normally you would write orders and specify telephone or verbal orders and fax to pharmacy. The next time the doctor is in he or she will sign the orders.

Specializes in Trauma Surgical ICU.

This is a very specific question for your facility, best to ask your charge nurse, NM, or someone that has been there longer than you..

Typically when the doc says "ok" to your request you write a TO and fax it to pharmacy with the medication name, dose, frequency and route and the PCP will sign it.

Specializes in Adult ICU.

The answers your looking for, depend greatly on your facility's policies and protocol. Though in our hospital, during admissions or any change of medication order, first doctor has to confirm the order, after that 2 nurses carry-out and signs their initials with complete time and date, then a copy will be send to pharmacy via fax or pneumatic tube.

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