I can't find the order for a med on the MAR/POS!

[Plagueis]

It's that time of the month: recaps (or changeover). There is a question that I have about what to do with orders that cannot be found in the patient's chart.

For instance, on one's of the patient's March POS and MAR, there is an order for a med dated January 28. However, it's not on the current month's MAR or POS, and I cannot find the original order for it anywhere in the patient's chart, either as a TVO, or written by the MD herself. Since I found this on the midnight shift, I asked other nurses what to do, and I've heard different ideas. (There is nothing in the facility's policy and procedure manual about this.)

One said it's a pharmacy error since I can't find the original order, so I should just D/C the order. Another said I should call the MD to verify if she actually ordered the med. However, I've found that in LTC, sometimes the MD's don't remember what they prescribed for their patients. (What if they say they didn't order it?) Another said to just leave it on the March POS and MAR, since it was ordered, but that the actual order could be in another chart.

I'm going to ask the manager when she comes in later about this, but I wanted to know: what do you do if you find an order on the new month's MAR and POS, but the original order is not in the patient's chart?

[silverbat]

I always look to see if the order was written on the POS in January, and if it was carried over into February, and look in the tab where the copies of written/oral phone orders are kept, to see if the order was written there. Then if it is no where to be found, I would call the physician.

[morte, LPN, LVN]

frankly i wonder if the pharmacies dont throw in the occasional "ringer"....i have seen things that simply cant be found/explained away.....good luck

[CoffeeRTC, BSN, RN]

Sometimes the pharmacy does make these errors. If you checked all the orders, the current MAR and looked in the nurses notes and MD progress report then it is probably and error. If you just cross it out, it will keep showing up on the printed orders for next month. I would do a clarification order to DC it.