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Discussion

how to note off orders

Do you note your own orders off that you do?I am from the old school,but I was trained that an oncoming nurse is to double check and note the order.I feel that if I note it off its kind of silly,My mistake will stay there and not get found,if there is one.Further more I have worked at some places where they dont note off.If you do it,what is your protocol?

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We draw a line down along side of the orders and underneath and sign them off stating that you have seen them. As they are completed we write "done" and circle it out to the side of each line. Anything not completed is easily identified and passed on in report to the next shift.

We always read the prior 12 hours worth of new orders with the oncoming nurse.

I'm on med/surg/tele. The charge inputs / notes off the orders, but we're still responsible for ensuring they were actually put it the system and that they get done. Then we do a 12 hr chart check with the outgoing / oncoming nurse, verifying that everything for the last shift is valid, in the system, complete / in process of, etc.

Each charge nurse is responsible for what happens on his or her shift, not the individual nurses. However, anything missed should be caught at the 24 hour chart check on nights.

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