Noting orders

[yadda_yadda_yadda, LPN, LVN]

I've searched old messages on this site & didn't find an answer to my question--hopefully, some other WA nurses can help :)

I work in a long-term care facility. Recently, I took 2 verbal orders from a FNP, on 2 separate residents. Here's the details:

Resident #1 : FNP requested a catheterized UA be sent out.

Resident was not on the unit @ the time the order was received. She was out celebrating her birthday with her family & due to return several hours after my shift ended.

I documented receipt of the order, completed the lab slip & passed the information on to the oncoming nurse in change-of-shift report. (Who indicated a plan to collect the specimen once the residnet returned from her outing)

QUESTION: Which nurse should have noted the order?--- My experience has been that the nurse collecting the specimen would be the one to note, as they completed the process.

Resident #2: Resident is not seen by our house MD or FNP, but has insurance & sees an outside provider. Outside provider requested a PT consult to evaluate her wheelchair cushion. Since she has outside insurance, an "external referral" must be processed through her insurance before in-house PT can see her.

The unit manager (also a nurse) would be the person responsible for actually sending any supportive documentation, fax any forms & communicate infomation needed for the referral.

I documented the rationale for the order received, notified the POA/family member & promptly informed the unit manager. The unit manager then processed the referral.

QUESTION: Who should have noted this order? My experience has been that "noting" means that I, personally, handled the order from start to finish.

If my name were on the order, as having noted it, one would think that I had completed all the steps to process the referral, right?

(If there were any questions or problems, the logical place to start inquiring WOULD be with the nurse having noted the order, right?):selfbonk:

I'm @ wits end...one nurse says, "Oh--that should have been placed on the treatment book!" ---- I've never placed 1-time cath orders in a treatment book.

She went on to argue that " if she took an order for Coumadin & noted it, that it didn't mean she'd be the only one to ever give the medication--and it didn't matter :uhoh21: who noted an order..as long as someone notes it"

Well, medication orders are another issue altogether, since, by "noting it", you've transcribed it onto the MAR, notified the pharmacy & taken all the steps to make certain that the order is carried out as written.--Noting it IN NO WAY means that you, personally, plan to give every dose. (yes, I think I work with at least 1 twit)

-----------------------------------------------------------------------------------------------------

The majority of my nursing experience is from another state, with the past 2.5 being in WA. I've never before had any situations like I've mentioned above.

I was taught that if you "note an order", you've seen it through to completion.

Thank you for listening--and providing insight.:icon_hug:

[Daytonite, BSN, RN]

I worked in 3 different states. In all 3, noting an order means I saw it, and I started the process to initiate the orders to begin. It doesn't mean that I carried them out to completion. That isn't possible with all orders, i.e. lab draws, diets, PT orders, consults. Signing off an order means you set things in motion. That includes properly communicating to the rest of the team that something needs to be done.