New to LTC, does signing off MD orders mean something different here?

AngelRN27 · Mar 9, 2013

I am having trouble understanding what you mean here... at my LTC facility, when a new MD order is received (either a TO or an order physically written by the MD while physically present at the facility) the nurse signing the "order received by" slot is acknowledging that the order has been transcribed in the correct places as you mentioned above (MAR, TAR, POS (depending on the facility), lab book/appt book, etc.). The night shift (11-7) then "chart checks" these orders to verify that the order was in fact transcribed in the correct places and that whatever follow up action was required (such as filling out a lab slip or writing a communication to the kitchen for diet changes) was completed as well. The pink copy is then initialed by someone on night shift signifying that the order was also double-checked.

What are you saying is different at your facility?

morte, LPN, LVN · Mar 9, 2013

Yes, you can "recieve" an order without "noting" the order. However, you have to go with the culture of the place. If the manager has structured things this way, you will need to fit in. Of course this means only one set of nurse eyes, instead of potentially two. Where I work, if I recieve an order, fax of TO, I sign my name for that. If I go on to noting that order, ie, putting into all the places it needs to go, I sign my name for that as well.

Hi, I am having difficulty adjusting to LTC and MD orders. I have 20 plus years experience in INPT, ICU, and ER; but am having difficulty understanding roles here. Is it different in LTC when you get a MD order? I was taught that you could receive an order without signing it off, e.g. a RBTO, but when you signed it off or noted it, that showed that you had taken responsiblity for putting it in all the appropriate places like the MAR, the computerized charting system (not yet using eMAR), entered the lab orders, made the appointment, or whatever the order states.
In my facility, we have a Resident Care Manager who asks that we put all the pink copies of the orders in a specific place, but she feels that signing in the "orders received by" space means the order has been completed (and it is not completed.) Does this happen other places. I am trying to find a policy/procedure that states how MD orders are to be processed, but can't find one. Does anyone have a source (even from nursing school) that talks about completing MD orders? Help!

MarggoRita · Mar 9, 2013

Sounds like your speaking about telephone orders? At our facility, whoever receives the order writes it on the telephone order slip, signs their name and time the order was received. They may not be the one to "take off" the order though, that is why "noting" the order is saved for last after all the steps have been completed, whoever completes taking off the order adds their "noted by" slash mark time and initials, then places the pink copy in the file for noc to 24 hour chart check.

BrandonLPN, LPN · Mar 9, 2013

Why would the person relieving the order and the person noting the order be two different people?

The person who "receives" the order should just go ahead and carry the order out.

I feel like I'm missing something

MarggoRita · Mar 9, 2013

We utilize teamwork, if I answer the phone and receive orders, sometimes for say ten residents at a time or however many that dr is responding to in that one phone call, I am not likely to stop my med pass long enough to take off all the orders as well, but the first available nurse on my shift (day shift) or else the oncoming shift may be the ones to jump in and take off the order if before I get back to it, or I may take off an order that was received by another nurse if I am the first one available to do so, regardless of who takes the order or who has that resident, we all work together.

BrandonLPN, LPN · Mar 9, 2013

Ok.

Where I work we have a doctor who is physically present and rounds 6 days a week, so telephone orders for 10 residents in one phone call is unheard of.

I can see where you're coming from.

AngelRN27 · Mar 10, 2013

Sounds like your speaking about telephone orders? At our facility, whoever receives the order writes it on the telephone order slip, signs their name and time the order was received. They may not be the one to "take off" the order though, that is why "noting" the order is saved for last after all the steps have been completed, whoever completes taking off the order adds their "noted by" slash mark time and initials, then places the pink copy in the file for noc to 24 hour chart check.

I was initially going to agree with BrandonLPN until I saw your second post. Our facility doesn't have a rounding doc like his, but I've never heard of an MD giving 10 orders in one call before at my facility. The maximum I can think of having at one time is 3. In the case that the nurse actually taking the order doesn't have time to note it in all of the pertinent places, they will "flag" the order for completion by the next shift or whomever can help out, but this is not the norm.

AngelRN27 · Mar 10, 2013

I'm still not 100% sure as to what the OP was asking, though. :bored:

auntiedebe · Mar 10, 2013

Our Resident Care Manager frequently "receives" orders, and then we are not sure what has been completed and what has not off the order sheet. In a situation like this, I was taught to note what had been done with the order, so it was clear to all that it had been completed. Receiving the order to me does not mean it has been completed. She "recevies" them as our MD is writing them. If receiving is the same as completing, then all portions of the order should be completed before the order is received.

For example, order #1 is a lab draw for CBC, CMP, UA; #2 is an order for a new medication; and #3 is for a dietary texture change. It was a MD written order, and she has signed it as received. Order #1 needs to be entered into 2 different computer systems-one for us and one for the drawing lab. Order #2 needs to be hand written into the current MAR and also into our computer system as well as faxed to the pharmacy. Order #3 needs to be communicated to the dietary department, the CNAs, the MAR (dietary section), and the RNs.

Upon researching, the MAR has been updated, the labs are written in a book, but not entered in any computer system, the dietary change has been communicated only via the MAR--which is frequently not looked at by the day shift until during breakfast. Our noc RN, me, has no LTC experience and was not told to complete 24 hr chart checks.

CapeCodMermaid, RN · Mar 10, 2013

I always hesitate to take off another nurse's telephone order. I take off the orders I've received. Signing the paper means ALL the steps of that order have been done, and from what I'm reading here, some of you don't have the best systems...two spots to document a lab draw?? Three spots for a diet change??? Ridiculous. Our nurses are supposed to do 24 hour chart checks. We will be all electronic within the next 6-8 months so even that will be easier to do.

DSkelton711 · Mar 10, 2013

Why would the person relieving the order and the person noting the order be two different people?
The person who "receives" the order should just go ahead and carry the order out.
I feel like I'm missing something

I am the DON and take orders over the phone and will put that I received the order. I then pass it onto the LPN to take off the order if I don't do it myself, so there are times when you will have a different person for those "steps". On our order sheet it has boxes to check off what you did with order (MAR, Lab order, care plan, etc.). Hope this helps.