Noting orders

[Dixiecup]

As we all know, in LTC we write tons of T.O.'s. Several of my co-nurses think that if you write the T.O. it is understood that it is noted, that you don't have to sign off the order.

I disagree with this. This is not what I learned in school (25 years ago!). Even if I write the order myself I still note it or else how does the next nurse that comes along know that the order was taken care of?

Thoughts?

[SuesquatchRN, BSN, RN]

We're on a computerized system developed specifically for LTC. It ROCKS. If your place in considering implementing an EMR, look into Sigma.

[caeRn]

it should be noted as TORB (telephone order read back) and yes you need to sign off the order!!!! That is a huge error waiting to happen !!!! Plus JC says you have to read it back to the doctor to verify so therfore you must document it!

[NurseLoveJoy88, ASN, RN]

I agree with you OP, all t.o. must be noted by the nurse that received it.

[Dixiecup]

my thoughts exactly. you just cant have it hanging out there on the page without someone noting it!

[rn4ever?]

Where I work, we would still sign off that order.

[CapeCodMermaid, RN]

All orders must be noted. And, don't forget, when the docs come in to sign off on the monthly orders, THESE must be noted as well. We won't have EMR till it's a regulation.

[shiccy]

I live in acute care & yes you must sign it off. It's hospital policy for us - you probably have a policy too