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how to keep track of dr orders

Nurses   (2,442 Views 14 Comments)
by PRETTYODD PRETTYODD (New Member) New Member

PRETTYODD has 2 years experience and specializes in med surg,stroke.

1,230 Visitors; 28 Posts

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I am sick and tired of being reminded that i missed such and such order. i forgot to do labs etc. I am less than a yera old RN and try hard to note and act on all orders but sometimes due to getting busy with other patients, i don't know when dr comes and writes on the chart. I am upset, depressed and frustrated that will I be able to do everything right?

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cokristinug specializes in Neuroscience/Cardiac.

1,300 Visitors; 60 Posts

On my unit, the secretary makes a copy of the Dr's order and puts it in the nurse's box (each nurse has their own box) so that we can review the orders and carry them out properly. It's also helpful because we don't have to keep referring to the actual chart since we have a copy for ourselves.

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10,622 Visitors; 400 Posts

is there a unit clerk that initially does the orders, then puts the charts with the new orders in a particular area labeled "new orders", then you check them off? if there is, let them know to page you if there are new orders. or check the new orders area more frequently during your shift. not knowing how your facility is set up limits the suggestions to be made to assist you. just my :twocents: :smokin:

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CNM 26.2 has 12 years experience and specializes in L&D/Postpartum/Newborn, Home Health.

2,554 Visitors; 52 Posts

I would suggest to ask other nurses on your unit how they do it. I suggest this because each unit is unique in how they do things-maybe there is already a process in place that you don't know about. Even if there isn't, some of the other nurses may be able to give you some suggestions based on the "flow" of your unit.

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2,491 Visitors; 60 Posts

Our unit also has individual boxes for each nurse and we get a hard copy printed out of all new orders. I couldn't stand having all that paper with me, so (when I worked daylight and had tons of new orders) I would frequently check my box and write down new orders in red and cross them out as I completed them. We got a new computer charting system in the past few years that adds a flag next to the patient's name when a new order is entered so it kind of eliminates the need for the printed out copy.

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19,750 Visitors; 2,227 Posts

Flip through the order sheets on your charts periodically, and at the end of the shift, to make sure you don't miss anything.

Write things down, have a "to do" list, cross things off when they are done.

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Sun0408 has 4 years experience as a ASN, RN and specializes in Trauma Surgical ICU.

35,830 Visitors; 1,761 Posts

When Dr.'s come to the floor and write orders they fold the new order so it sticks out of the chart. The charts are always with us because we have a pod set up at our hospital. Meaning 6 rooms in one area with the charts, mac and a documentation computer. We almost never see the Dr.'s come in so they leave it on our desk. For the orders after they are in the computer we write them on the kardex.. This is how we do it on our floor... I agree, check your charts frequently. Dont sign them off til they are completed or passed to the on coming shift if unable to do on your shift.

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2,288 Visitors; 63 Posts

The underlying theme here is that you need to find a way to work within the system at the facility you work and develop a practice for MD orders that makes sense to you and is compatible with your work habits. I remember learning this early on, simultaneously realizing I couldn't count on a ward clerk to notify me of new med orders as I had been told was the norm. This while phoning the doc to tell him I'd given a med that had been dc'd....Have heart, this is what turns you into an "experienced" nurse!

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3,427 Visitors; 151 Posts

know who your pt's doctors are....

some of them dont put the charts in areas where charts are to be put to be processed by unit clerks/ or you....some of them leave them scattered around etc...

if you see the pts dr come in to round, automatically look at the pts chart to see if he/she wrote anything new.

unit clerks are a godsend, but working nights, we dont always have one.

also, im pretty sure that most places employ the 12 hour chart check.

that should help you catch any orders that need to be done.

its frustrating when orders go unnoticed, but it happens.

just make it part of the routine to check any pt that you have on your assignment for orders.

of course this can be impossible if you work ltc

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PRETTYODD has 2 years experience and specializes in med surg,stroke.

1,230 Visitors; 28 Posts

i work nights and there is no unit clerk in nights. but dr's come at 4 in morning write order and disappear and its close to end of shift. Many day nurses pass on their orders to us and that is very frustrating.

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9,963 Visitors; 686 Posts

Do a chart-check before your shift is over, ideally towards the end of your shift to check routinely if all orders were taken off.

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8,104 Visitors; 979 Posts

I scan for my pts' charts constantly. This is a worthwhile habit. If a chart's not in the rack, I find out where it is--is it waiting for someone to take off orders? Is it waiting for me to verify orders? Is it abandoned on a charting desk because a doctor forgot to put it on the rack to have orders taken off? Is it on the charting desk in progress with the doctor in the rooms? And at the beginning of every shift, I look to see if any of my charts are awaiting nurse verification or secretarial order entry. I just noticed I typed "my charts." I guess that's the attitude that works for me. They're not an imposition in any way, they're an important tool in getting my pts healthy.

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