Medicine Orders??

[DaSuperRN]

Okay, I had posted a question on the forum about med orders in HH, but I erased it during an emotional minute now I am reposting it.

For future references:

Gees, I hate to be so critical but the MAR med ,and TAR tx orders I saw at a clients were unlike any I've seen before. All the orders were together on one paper carrying over to the back. The times were written as am and pm no specifics, there was one wound care tx, but it has no times, where is the wound and what to use was not included. Plus, there were no diagnoses on any of the orders. I was shocked. Tell me this is not standard protocol in HH, right? I mean orders are supposed to be specific and to the letter. I do not know who transcribe them, nor do I know who obtained them. The physicians orders are all haphazardly in a black note book with, NN and other pertinent information.

:Snow: So cold here.....

[alintanurse]

I do intermittent snv's in home health and there should be a med sheet specifying med times,administration route and parameters if necessary. There should also be a wound record with type/size and location of wound. A treatment sheet should also be in the home with the MD orders for wound care. Supplemental orders should be in the home record also with the updated Md orders. Your agency seems to lack a system,--that can lead to lots of errors,you need to be careful. You may have to go to the office and look through the hardchart for the information needed.If it's not there either than have your supervisor call MD for orders.

[DaSuperRN]

I do intermittent snv's in home health and there should be a med sheet specifying med times,administration route and parameters if necessary. There should also be a wound record with type/size and location of wound. A treatment sheet should also be in the home with the MD orders for wound care. Supplemental orders should be in the home record also with the updated Md orders. Your agency seems to lack a system,--that can lead to lots of errors,you need to be careful. You may have to go to the office and look through the hardchart for the information needed.If it's not there either than have your supervisor call MD for orders.

Well, I knew is was not setup correctly. I have been in nursing over 10 years and I've seen times mostly in LTC where doctors orders would lack either specifics or a diagnoses, but we would get on top of it.

Let me ask you this is there a particular person, one single person that goes around from home to home checking up on these things? As I stressed I am new to HH, and I probably should be asking someone in that agency, but I have hit numerous brickwalls. I am just thinking in my mind someone would have to be in charge of overseeing things in these homes.

Darcy

[alintanurse]

It's up to each nurse that follows to update and maintain the home record. The supervisor should be providing the nurses with copies of changed MD orders so that you are compliant with tx's,meds etc. The hard chart in the office should have all pertinent info. As far as one person to go to, I would approach your supervisor or nurse educator or QA manager. Also you could bring up this issue at your staff meetings,but surely someone else has noticed the sloppy charts. No one at the agencies I've worked at ever went to the home to check up the home chart accuracy. There's definitely a problem with your agency,so be careful to protect your license.

[DaSuperRN]

It's up to each nurse that follows to update and maintain the home record. The supervisor should be providing the nurses with copies of changed MD orders so that you are compliant with tx's,meds etc. The hard chart in the office should have all pertinent info. As far as one person to go to, I would approach your supervisor or nurse educator or QA manager. Also you could bring up this issue at your staff meetings,but surely someone else has noticed the sloppy charts. No one at the agencies I've worked at ever went to the home to check up the home chart accuracy. There's definitely a problem with your agency,so be careful to protect your license.

Well, I am not planning on staying with this agency, but I am planning on staying in home health care. I just have a bad feeling in my solar plexus i.e. a gut feeling about this one. Thank goodness I found this part of the nursing forum.

I do private duty which means I can be at a home from 4-10hrs or longer depending on the need. I have not been able to do much since I joined this agency because number one there are not many adult clients, and I have not got a good orientation yet.

So I need to get together with my Supervisor in person, which she is 2 hours away at the main office.

Thanks for all your support!

[alintanurse]

Glad to help! Always follow your gut feelings,I also worked for an agency that was unorganized --I notified the supervisor about the problems with the home charts and that I felt my license was on the line. I stopped working there because I didn't want to risk losing my license.