Noting Physicians orders

[RN1964]

I am looking for a best practice and procedure for noting physicians orders

I can not find a regulation on this and i am educating nurses on a best practice procedure

Basic standard is to note the order once recieved than a second nurse is to double check and note the orders finally night shift is to recheck the charts on the units and check all new orders of the day for accuracy

Does anyone else have any Ideas.

Thank you

RN1964

[CapeCodMermaid, RN]

I've never heard of or seen in real life the method you describe. The nurse who takes the order off notes it. 24 hour checks done by 3-11. Never heard of a 3rd check on an order. On our subacute unit, that would mean the nurses would almost have no time for anything other than noting orders. It's not uncommon when the medical director makes rounds for him to write new orders on all his 28 residents.

[oneLoneNurse]

I have seen this done before, somewhere. I don't necessarily think its a bad idea. Its like double checking insulin which at our institution we don't do.

Where I work now, the order is inputted into the system and the pharmacist verifys the order before it is filled. Pretty cool, it has to come over from the ordering system into the pharm system(HL7).

I've never heard of or seen in real life the method you describe. The nurse who takes the order off notes it. 24 hour checks done by 3-11. Never heard of a 3rd check on an order. On our subacute unit, that would mean the nurses would almost have no time for anything other than noting orders. It's not uncommon when the medical director makes rounds for him to write new orders on all his 28 residents.

[brina]

I work in the Pediatric ICU and the nurse who initially fills the order is the one who notes it. Finally a 24 hour chart review is done on all orders for the past 24 hrs by the nite nurses anytime after 12 am.

[htrn]

If we take a verbal or phone order, we can enter it into our computer system and sign that we entered the order, but a different nurse has to verify. As long as there is a second nurse that sees and verifies the order, we consider ourselves covered.

[LPN1974, LPN]

The procedure at my facility is that dayshift does the orders, and notes the chart.

Evening shift checks the chart to make sure it was noted, and we put the charts away.

However, with our new computer system for entering orders and giving medications....the PM nurses don't have time to go into the computer and recheck every order behind the day nurses. It just doesn't exist. We have heavy med passes to do and have to get out there almost as soon as we get to work.

But we do check to see it was noted.

We also date and time our orders along with our intials.

[RN2B07]

In my facility when an order is taken it cant be noted by you, another RN must note for you. Then day shift does 12 hour chart checks and also night shift will do the 24 hour chart check.

[grentea]

RN 1964-Usually at my hospital, the MD will write the order, the secretary takes it down, and the RN checks it. Then of course we have have to do a chart check for every shift. If it's a verbal, I take it down, maybe hand it to the secretary if it involves a lot of entering orders in the computer and I recheck it. I've really been having a fun time this past week because there was a one doctor who didn't know the date but was writing orders all over the hospital with the wrong date. If I see a doctor who I know has messy handwriting, I don't just let them shut the chart when they're done writing and walk away, I have them read me their order. I've really had it with messy handwriting, leaving important things out of orders (like the route of a med), and just the large amount of calling up MDs I've been doing to have them clarify their orders or give me the orders I actually need. It drives me nuts when I'm so busy already! I keep wondering......WHEN WILL MY HOSPITAL GET COMPUTERIZED PHYSICIAN ORDER ENTRY?!

[RN1964]

Thank you all for youe input

RN1964