Is there an easier way to keep up with new orders?

systoly · Nov 4, 2009

Ooh that sounds sooo familiar. First, I gotta say it (knowing it's of no help at all): This is your boss's job!!! Ah, now I feel better. There are numerous things that can be done. Do you have a unit secretary? Do you have admission packets? It sounds like you're primarily dealing with one doc, your medical director? Do your charts have slide tabs on the outside? I know I'm asking questions instead of offering suggestions, but how you address this depends on your situation. Earlier this year, my wife introduced a plan of action on her floor that adresses this very problem. It has since been adopted on all the other floors of her facility and has all but eliminated missed orders, labs, admission notes, etc. I will consult her on this and post or message (with your permission).

Schmoo1022 · Nov 4, 2009

I just left a place like this. I loved everything about the job except, I felt I was sinking. Let me know if you figure something out. My place was a very busy short term floor at a LTC facility. There were labs everywhere. I couldn't figure out was reported and what wasn't. There were like 8 different Dr's plus their NPs and 50 residents. Plenty of staff, just so disorganized.

sasha2lady · Nov 7, 2009

Luckily we have ONE doc..whom each and every one of us nurses LOVE and ADORE. He will be retiring next summer and we'll be getting the most despised MD around so I look for a lot of job openings...anyhow....I do agree...its her job..but get this. The normal RN charge that does this stuff with the doc , the DON piles more and more onto her and expects it to be done..yet she cant do one days worth of orders and rounds with him herself? I work 2nd and the nights before he comes in I go through his whole box and separate every single thing in it. I clip consults and other papers that he needs to sign or approve in one stack, I clip orders in one stack, labs are another stack and any admissions are a stack. So...when he comes in him and the RN charge are both in order. This doesnt get done if I happen to be off the night before so its a mess when he comes in. With labs, I highlight anything thats abnormal but not emergent as some labs are always off b/c of a chronic illness. I go ahead and fax things that need to be faxed to whichever place ahead of time so the RN doesnt have to do it and I write it on the sheet so she'll know its been done. That shaves some time off of her day. I look in his book for things that I can go ahead and take care of when I call him every night...then mark it off so that it also cuts time. If I had known what a mess I was going into that day I probably wouldnt have gone. The DON is famous for telling us stuff like " make sure you have the chart in front of you when you talk to the doctor".....and she does things the long hard way. Prime example...I had to get a bunch of orders clarified on a resident that had moved from rest home to skilled...that in our place is a whole new admission b/c its a level of care change. NOTHING was done! This pt was on aricept 5mg bid. umm..why? It can be done qd at hs 10mg. She wanted me to go allllll the way up to the social workers office and wait for her to get me a copy of a pysch consult from who knows when to clarify that med when the doc was sitting right there! I just said..."ok" and turned to him and told him what it was and could we change it and he said "yea, thats fine". Simple enough right??? why go through all that. She is so bad for digging and digging through a bunch of charts and never finds what she is looking for. To have her work on anything with an admission is WORSE...yes...worse! She will sit at that desk for 3 hours...no lie....and write out a mar for this person when it takes the rest of us...less than 30 mins unless its one of those FL2's that is impossible to decipher and we have to get on the phone with whatever place they came from. In 30 mins I can get a mar done, fax the mar, and the fl2 to the pharmacy and have them on the phone to tell them to get those meds out stat plus have my new chart in exact order and flagged with what I need to do. And in this time my rehab aide who is a GOD SENT angel to me and my shift already has a list of vitals, ht and wt for me plus any info I might need to know like...if they can hear good, dentures, can they stand etc,,are they confused??.....We rarely have an admission packet though.....the medical records person is supposed to have new charts ready when we get an admit but 98% of the time we dont even know we are getting one til they roll thru the doors. We dont know when one is being discharged either usually til the day of d/c. we dont have a ward clerk of secretary yet..but the don is actually trying to get us one come jan/ feb. right now we have a volunteer 2 pm's a week who just answers the phone. Since I dont know if she will actually be on the payroll yet..I dont know if its worth the time and effort to show her more paperwork etc that she can do. Shes only there for about 3 hrs at a time anyhow. When the evil, hateful doc covers for our current one, he comes in on my shift to do rounds..which is terrible b/c there are only 3 of us nurses and we all are on a cart with 30 residents each and have to do our own txs, charts, and other stuff. This doc..as hateful and non nurse friendly as he is...we have one thing in common....organization. He has to have every single chart w/ a copy of that pts mar banded to it and he goes room to room and writes his orders and we take the completed ones from him and process them. Time consuming but simpler in the end. What kind of system did your wife put into place? I have to meet w/ the don sometime next week she wants to go over some new changes that are coming to us full time people before she puts it out there for the rest of the staff to see what might need improvement or changing. I am definitely open to ANY suggestion with this so I can put it on my list to go over with her at our meeting.

systoly · Nov 7, 2009

You are very organized and what you are doing is not much different from what my wife does. The trick is to get everyone on board. Anyway, she always has admission packets ready with a check off list. You don't need to have the actual chart to put together an admission packet. She has a binder for new orders. Whenever there's a new order, be it a new admit or during rounds or because of a change in status, every new order is copied on a separate sheet for each order ( so for a new admit you may have 20 sheets or more) and placed in the binder. Whoever works a particular order checks or writes down what they have done or what still needs to be done for this particular order. For instance, if you get a new admit toward the end of the shift, and one of the orders was PT/INR in two weeks, there would be no need to make out a lab req. right away, however, it would show up as not yet worked in the binder. Each nurse is responsible to check the new order binder for unworked or not completely worked orders as far as 24 hours (usually three shifts) back and work whatever has not been completed. Also, each nurse initials and checks or writes down what he/she did. Copying all the orders in yet another place may seem cumbersome et redundant at first, but not only has it cut down on missed orders, it also places all orders in one central location and it distributes responsibility and acountability across the shifts. I hope this helps a bit.

sasha2lady · Dec 21, 2009

The DON has started putting a checklist in all new admit charts and readmit charts...but...for example....lets say I get the admission and I do everything except for 2 parts of it....what we are to do is take this sign off sheet and give it to the oncoming nurse who is then supposed to look at whats left to be done and do it.......I give it to the next nurse.....and of course....its not done. This is the continual problem....for example if we have 10 full time nurses, 3 of us do the brunt of the work and that goes for all 3 shifts. The rest do as little as possible out of spite for the DON, or they say "I dont know how"...even though I myself have taken the time several times to show these dont know hows......how to do this paperwork. 3rd shift is supposed to do chart checks nightly.....Im finding chart checks that were last done in AUGUST 09! Usually when the DON makes us try a different way of doing things.....it ends up failing because she adds to the paperwork, more papers mean more to fall through the cracks....and there is no explanation of new paperwork...she just hangs up a note that only a few of us see and actually understand...then she expects it to be explained by word of mouth which again....is a failure every time. So, I guess Ill just worry about keeping myself organized since every time I make a suggestion it falls on deaf ears. They can have their chaos.